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Trailblazer: Dr Ann Lewis, GP Obstetrician Battling Diabetes in Carnarvon Central Referral Service Hurdles of Telehealth Patient Blood Management
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Travel: Cruise Control Dr Ruth Highman: Ocean Paddler Knee Deep Wines Review – Dr Louis Papaelias The White Album Revisited Funny Side Ancient Anecdote: Diabetes in the 18th Century Social Pulse: Hollywood Clinic Extension Opening WA’s Action Hero Competitions
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Editorial: Testing the Mood of the Health Electorate Letters: Improve Options for Unintended Pregnancy – Dr Andre Schultz Listening to Consumers – Mr Roger Cook Common Sense in Short Supply – Dr David Borshoff Ruby’s Case is Complex – Mr Michael Mischin Stigma of Hep C – Mr Frank Farmer Antenatal Shared Care Guide – Dr Vicki Westoby Outrage is Relative – Dr Phillip Noble Have You Heard? Beneath the Drapes Superannuation and Assessing Risk Working Guide for RACFs Diabetes Support Groups ps Western Cardiology Student Scholarship s in
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DR GORDON HARLOE New Clinipath Pathology Laboratory
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Viewpoint on Iron Balance
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SMATHI 35 DR CHONG Unwelcome Microbial Souvenirs
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Preventing Diabetes Eye Damage
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Hot Topic of Ethical Super 2
Editorial By Dr Rob McEvoy Medical Editor
Fixing healthcare has become decidely unhealthy. Health consumers do not need government to wade in with a different ideology, busting things up, and being wasteful of limited resources. It doesn’t matter which part of the political spectrum you come from. Health consumers and doctors have got the message. No pain, no gain. There’s not enough to go around, so let’s do things smarter not harder. Here at Medical Forum we get a flood of media releases at Budget time. Some before Budget night as government leaks what it wants to leak or groups try and bring pressure to bear. Most happen afterwards. Why? The author groups are hoping to garner support through the media. So everything gets dressed up to provoke a response. It’s like a swarm of bees trying to work out the most sensitive areas to bite you. It has been particularly bad this year with a Senate likely to reshape the government agenda in ways that gives them the best mileage. This is squeaky door politics at its worst.
Testing the Mood of the Health Electorate The medical profession, a conservative lot, scratch their heads while getting on with the job. The work they do is always under some government influence, whether direct through connections with hospitals, Medicare, Centrelink, etc. or indirect when family members get sick. Every doctor has an insider view on something. I think they are becoming increasingly dismayed by what they see – a lot of political posturing while the nitty gritty of caring for people is getting more difficult. Most doctors are analytical thinkers – weigh up the options and try and make the best decision for the outcomes needed. I’m not sure what type of thinkers most politicians are. Keeping the majority of electors happy is important, as is the art of creating expectations and fears, which in turn drives happiness levels. Is the pain of belt-tightening being shared equitably by the profession? If the flurry of media releases from the RACGP is anything to go by, primary care feels particularly poorly done by in the Budget, in many respects. It appears somewhat ironic that
GPs are being asked to collect a co-payment from health consumers (including the disadvantaged) for medical researchers. Specialists do the lion’s share of research amongst doctors. The co-payment is potentially divisive for the profession and research may not be futureproof. Other research funding may be cut back, or medical research becomes politicised to replace the ‘working party’ or ‘inquiry’ as a marker of government indecision. The federal AMA has said it is concerned that the freezing of specialist rebates, along with GP co-payments and other things, was shifting too much cost to health consumers. Maybe it’s a side effect of ‘whoever pays the piper calls the tune’, but it is interesting to note that media releases are congratulatory on some things, while giving a backhander on others. Some are blatant in their criticism, such as the Australian Nursing and Midwifery Federation, which has called on balance-of-power parties to save Medicare! Two weeks is a long time in politics – that’s the time until we go to press – and there are many who hope that’s the case.
Letters to the Editor
Improve options for unintended pregnancy Dear Editor, Your guest columnist [Abortion Obstacles Remain, April edition] describes numerous ways to improve access to abortions in WA. As a paediatrician, I take particular issue with the suggestion to remove limits to abortion of late gestation pregnancies. With the exception of their location, there is no difference between late gestation foetuses and premature babies who are currently receiving care in our neonatology units. In 2009, there were 30,305 live births in WA and 8885 induced abortions, suggesting that access to abortion is not a major problem. For young women, less than 19 years of age, there were 1595 abortions and 1468 live births. Instead of increasing access to lateterm abortions, prevention of unintended pregnancy should be a priority. The newly released results of the fifth National Survey of Australian Secondary Students and Sexual Health show that almost a quarter of year 10 students have had unwanted sex, with alcohol intoxication cited as the most common reason for having unwanted sex. For young people, unwanted sex in a state of alcohol intoxication is not usually associated with contraceptive use. Efforts to reduce alcohol misuse in adolescence would be a logical course to pursue. Another priority should be pregnancy support services, especially for adolescents. The very high abortion rate in young people is concerning and begs the question: “How many young women had abortions because they did not perceive themselves to have any other option?” Outcomes for young mothers and babies are vastly improved if comprehensive support services are available during and after pregnancy. In WA, such services are extremely limited and mostly funded by charitable donations. It is time for our government to provide adequate pregnancy support services that empower women who are pregnant and in difficult situations to continue with their pregnancies if they should choose to do so. Dr Andre Schultz, Paediatrician
Listening to Consumers Dear Editor, The emergence of online and social media in health has the potential to dramatically shift the relationship between the patient and their health care provider. A patient can access information on their 4
symptoms forming a pre-appointment ‘diagnosis’, can research the medications prescribed to them, and can do a background check on their health care provider. A friend of mine, living in a country town, was able to undertake extensive research into her son’s congenital heart condition to the point she was able to engage with local GPs, potentially knowing more about her son’s rare condition than they did. Social media similarly places a powerful (although not necessarily accurate) information tool in the hands of the patient. Information flow in an unfettered online forum means the health consumer has been greatly elevated in the information balance between themselves and the provider. So the question is whether there is a role for government to intervene in the market to either further enhance the information available to the health consumer or regulate the market to ensure the information is accurate or plays a constructive role in improving the operation of the market. There is already evidence that governments are choosing to do both. One particular initiative is the use of social media to survey hospital services. Patients are surveyed at the admission, treatment, and post-treatment stages of their care journey to provide real-time feedback on their care including the quality of outcomes, how they rated the care provided by their doctor and/or nurse, and the quality of the services and facilities. Hospitals should have patients at the core of their being. Responding to patient feedback and needs is an important element of this patient-focused culture. Online and social media has an important role to play in facilitating this two-way information flow and I would like to see governments taking a more active role in making this happen.
Infection Control with its voracious ‘single-use’ appetite, both consumes health dollars as well as the earth’s resources and obediently feeds the medical industrial complex. It also begs the ethical question of the enormous expenditure for the last small percentage of sterility gain while Third World countries struggle for vaccines. Add to this patient empowerment enabling formal complaints, regardless of the trivial nature of some, and practitioners are tied up for hours writing reports rather than providing patient care. I am not at all suggesting that legitimate complaints should not be dealt with appropriately, but in an age of ‘defensive’ medical practice, instant gratification and a media hungry for news, the pendulum has swung and few voices have the courage to call it. Finally, significant health-care dollars are being spent each year on ‘mandatory modules’ that all practitioners in the public system have to complete, regardless of experience or knowledge. Modules on ‘Sterility’, ‘Child Abuse’, ‘Manual Handling’ and any other topic dreamt up by middle management in response to some media sound-bite continues to load the already overburdened public system to such an extent that delivering decent care is like wading through mud. In the meantime, while we complete the modules, waiting lists grow. I agree with Dr Majedi, but it will take an extraordinary leader to implement the necessary changes, and unfortunately I don’t see too many of those in our health care system. Dr David Borshoff, Anaethetist
Continued on P6
Mr Roger Cook, State Opposition spokesman on Health
Common sense in short supply Dear Editor, Dr Majedi courageously opens Pandora’s Box with his questioning of sustainability in health care [The Pain Perspective, May edition]. His last paragraph asks for “ethics…and realistic expectations ahead of commercial and political gain”. Perhaps ‘common sense’ should also be added to that cocktail. The growth in Human Resources in the public system has consumed millions of dollars. Minor conflict that could once be resolved with common sense by a Head of Department is now dealt with ‘formally’ by HR, taking months and sometimes years to resolve.
Joke Timing is Everything A guy shows up late for work. The boss yells “You should have been here at 8:30!” He replies: “Why? What happened at 8:30?”
Letters Continued from P4
Ruby’s case is complex Dear Editor, I refer to the opinion piece by Mr Geoff Diver [Frozen in Time, May edition], concerning the death of his daughter and the time that it has taken for an inquest to be held. Mr Diver and his family, and his daughter’s friends, deserve our sympathy, and I am concerned at any delay in a timely resolution of an inquiry into an unexplained death. In this case, however, it is not exclusively a case of inadequate resources. Any inquiry by the Coroner is preceded by a police investigation. Ruby died on the night of 1-2 March, 2011, but the investigation report was received on 8 August 2012. It was not until then that the Coroner’s office could evaluate the available evidence and commence its own inquiries. Cases which proceed to an inquest often require a great deal of additional work beyond that of the initial investigation, for example reports from treating physicians, and these may be delayed depending on the level of co-operation from witnesses and follow-up work required. Once this is completed, the court brief is prepared. At the direction of the then State Coroner, Ruby’s case was married up with other cases touching on the quality of mental health services provided at Fremantle’s Alma Street Clinic. Obviously, where multiple cases are combined, matters can only proceed to a hearing at the pace of the ‘slowest’ case. Also, other, unrelated, cases may from time to time have to take priority, as the Coroner decides. However, I understand that both the former and current State Coroner have issued instructions to counsel to clear as many of the older cases as possible so as not to prolong the distress of families or lose any benefit that may emerge from holding an inquest. The files for this inquest are currently with senior counsel assisting the Coroner for preparation for the hearing. Counsel assisting the Coroner has been in regular contact with Mr Diver to update him on the progress of the case, the last contact being in February 2014. The government recognised that additional resources were necessary to support the Coroners Court and in in its first term allocated temporary resources to help clear the backlog of cases. These have since been made permanent and supplemented. Accordingly, staffing levels have increased, including two new full-time Coroners and two full-time counsel assisting. The total number of cases on hand reached a record high of 2460 in September 2011, and is currently 2034 as at March 2014. 6
Since Ruby’s death, there has been a dramatic reduction in the number of backlog cases from a record high of 938 in September 2011 to 493 in March 2014. More than half of all backlog cases are awaiting external agencies supplying information before a Coroner can make a final determination on the matters. In relation to inquest cases, the total backlog has reduced from 158 cases at the end of 2012-13 to 130 cases at the end of March 2014. In the past preceding nine months, inquest cases older than four years decreased from 23 cases to 11 cases. Inevitably, delays will continue to occur as each case is different. However, I am confident that under the committed leadership of our new State Coroner, Ms Ros Fogliani, and the resources now at its disposal the Court is in a position to meet community expectations. Mr Michael Mischin, Attorney General of WA
Stigma of Hep C Dear Editor, HepatitisWA is asking for your readers their continued support in tackling stigma and discrimination against people with hepatitis C. There are 230,000 people across Australia living with hepatitis C, many unaware of their status, while others may be reluctant to disclose they have the disease. Studies by the Centre for Social Research in Health (CSRH) and the Australasian Society of HIV Medicine (ASHM) have shown that discrimination is a barrier for some in accessing treatment and make positive lifestyle changes.
We are calling on doctors to raise awareness of the facts around hepatitis C with a view to increase access to testing, treatment and care for people living with hepatitis C. So what can you do? It is important that your patients feel that they can speak to you openly and honestly. HepatitisWA can also offer you and your patients information and support via our website and our new ‘C the person not the disease’ campaign. www.hepatitiswa.com.au. Mr Frank Farmer, Executive Director, HepatitisWA
Antenatal shared care guide Dear Editor, KEMH has recently published the fifth edition of the Antenatal Shared Care Guidelines for GPs, which aim to provide clear information for GPs involved in the shared care of low-risk antenatal patients with KEMH. A hard copy of the guidelines is being sent to general practices for the attention of the Practice Manager. The guidelines are also available on the KEMH website: www.kemh.health.wa.gov.au under the Health Professionals link. If practices require more hard copies, they are invited to contact Wendy Rutherford (ph 9340 1393 or email@example.com) Key changes in the new edition include: t 6QEBUFEQPTUDPEFTGPSUIFDBUDINFOU area for metropolitan maternity services: Antenatal referrals are now outside the scope of the Central Referral Service and GPs should refer low-risk women directly to their local maternity service. Continued on P8
Joke Heaven Can Wait Sid and Irv are business partners. They make a deal that whichever one dies first will contact the living one from the afterlife. So Irv dies. Sid doesn’t hear from him for about a year; he figures there must be no afterlife. Then one day he gets a call. It’s Irv. “So there is an afterlife! What’s it like?” Sid asks. “Well, I sleep very late. I get up, have a big breakfast. Then I have sex, lots of sex. Then I go back sleep, but I get up for lunch, have a big lunch. Have some more sex. Take a nap. Huge dinner; more sex; go to sleep, and wake up the next day.” “Oh, my god,” says Sid, “so that’s what heaven is like?” “Oh no,” says Irv. “I’m not in heaven. I’m a bear in Yellowstone Park.”
By Dr Gordon Harloe Chief Executive Ofﬁcer, Clinipath Pathology
New Clinipath Pathology Laboratory In January of this year, Clinipath Pathology was handed the keys to its purpose-built laboratory at 310 Selby Street North, Osborne Park. A milestone marking the end of a design and construction phase, and the beginning of a new phase to relocate to the state-ofthe-art premises. The entire laboratory and WA Specialist Clinic have now moved to the new facility.
communication and teamwork throughout. Workflow was a critical area upon which the design team placed particular focus; ensuring that the sample journey throughout the testing process is streamlined and those critical functional areas such as couriers and specimen reception have the most efficient flows allowing the clinical areas to commence testing specimens as quickly as possible.
The 5600sqm premises were long overdue for our business of providing diagnostic
The fitout supporting the laboratory operations is based on hospital grade
QThe Clinipath Pathology laboratory, 310 Selby Street North, Osborne Park
pathology in Western Australia, particularly following the acquisition of Healthscope Pathology in late 2012. Clinipath Pathology had been based in our West Perth premises for nearly two decades, growing from a small private pathology practice into one of the leading diagnostic pathology providers within WA. Our practice’s commitment and dedication to quality has ensured our growth and longevity in the challenging environment which all Medical Practitioners operate within. A project of this magnitude and significance to the business has been a challenge that all at Clinipath Pathology have risen to. Close consultation with the lead architects at Hames Sharley during the design phase, and then a working relationship with the builder, Credentia Construction during construction resulted in a facility that allows Clinipath Pathology to ensure that we continue to meet the clinical needs of our referrers and patients to the high standards of quality we all expect. The design was based on a functional, open-plan layout which facilitates
design and materials that other such medical facilities within the country are deploying. In addition to the knowledge of colleagues throughout the country, a great deal of effort was put into the design and fitout of specialist departments such as Histopathology and Molecular Pathology where functional design is driven by requirements to protect the staff and specimens from contamination. In practice, these efforts have proved worthwhile and the Histopathology department is now being considered a model for other such departments within the country. The additional physical space provided by the new premises has allowed Clinipath Pathology to commission additional critical instruments within the Biochemistry, Haematology and Microbiology departments. The aim of these additional instruments is to not only continue to improve testing turnaround time with parallel processing but expand the range and accuracy of testing performed. For example, Clinipath Pathology
Main Laboratory: 310 Selby St North, Osborne Park General Enquires: 9371 4200
Patient Results: 9371 4340
For information on our extensive network of Collection Centres, as well as other clinical information please visit our website at
is the first laboratory in Australia to install the Roche XN 9212 haematology platform, with advanced features which include an accurate estimation of a low platelet count through the immature platelet fraction and the fluorescent platelet count. We have also just taken receipt of a MALDI-TOF (matrix assisted laser desorption ionization timeof-flight) for our Microbiology department. When used on positive blood cultures, MALDI-TOF can provide genus and species level identification in minutes, enabling significant time savings over traditional identification methods. We look forward to providing you more information on these exciting technologies in the near future. Relocating a practice of the complexity and size of Clinipath Pathology required detailed planning and coordination. The mantra for the relocation was communicated from the outset; “The relocation of the Clinipath Pathology main laboratory will be seamless to our customers. Turn-around time, quality and responsiveness are to be maintained at the levels all our Clinical, Corporate and Individual customers currently enjoy.” Understanding that the needs of the clinical community are paramount, I was unwavering on this direction throughout the relocation. Methodically relocating each department ensuring that key medical instruments were commissioned, results correlated and signed off for complete accuracy over three months ensured that there was minimal impact to the patients and referrers of Clinipath Pathology. Quality is getting it right. In addition to the Clinipath Pathology laboratory, the premises at Selby Street North, Osborne Park, includes the WA Specialist Clinic where Drs Tampi, Glendenning, Barr, Cannell, Chong, Herrmann, Martinez, Watson and Wright have relocated. This clinic includes additional consulting rooms and expanded facilities for patient infusions to address the growing needs of the patient community. A new, large collection centre has been opened at 630 Murray Street to cater for doctors and patients who require a West Perth collection facility.
Letters Continued from P6 t 3PVUJOFJSPOTVQQMFNFOUBUJPOGSPN weeks gestation using iron preparations with high elemental iron and a low threshold to order iron studies at 28 weeks (if at risk of anaemia). t (FTUBUJPOBM%JBCFUFT4DSFFOJOHSPVUJOF screening with oral glucose tolerance test at 24-28 weeks if low risk, screen earlier if high risk. t "EEJUJPOPGJOGPSNBUJPOBCPVU/PO invasive Prenatal Testing (NIPT) and PAPP-A plus the significance of low PAPP-A with normal chromosomes. t 3FE$SPTTTVQEBUFEQIPOFOVNCFSJT 9325 3030 if GPs need to access anti-D. t 3FDPNNFOEFE(1GPMMPXVQGPMMPXJOH postnatal complications including postpartum haemorrhage and pre-eclampsia. KEMH values the role of GPs in providing shared antenatal care and is committed to provide ongoing support to GPs who provide this care. Dr Vicki Westoby, KEMH Liaison GP
Outrage is relative Dear Editor, I read the editorial [Moral Outrage in Mental Health May edition] and was challenged to ask â€“ â€˜on what basis are we are claiming this outrage?â€™ Evolutionary Theory (ET) states that any organism only exists to pass on its genes. If that fails to be the case then there may be a sense of loss, but certainly no outrage. ET does not provide any basis for â€˜moral outrageâ€™ and certainly there can be no blame for survival of the fittest and by implication non-survival of the unfit, on anyone else or any societal structure. In fact ET would say that only the fit survive and this is good for evolutionary genetic strength. So then we have to turn elsewhere to see the basis for any claim on this moral outrage.
Where do we see a claim that life itself is precious, to be valued and nurtured, a call to tend to the needy, downtrodden and helpless, the destitute and those who cannot help themselves, or speak for themselves? Is it not from those great religions that espouse a personal responsibility to a personal God? If that is the case, then the inference is that we cannot claim â€˜moral outrageâ€™ unless we are living within the â€˜Personal God/personal responsibilityâ€™ framework. Dr Phillip Noble, GP Cockburn
We welcome your letters. Please keep them short. Email to firstname.lastname@example.org (include editor@mfo full address aand phone number) by the 10th of each month. You can also leave a message at www.medicalhub.com.au. Letters may be edited for legal issues, space or clarity
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Left Ventricular Hypertrophy: common and rare causes Left ventricular hypertrophy (LVH) is prevalent and is associated with a poor longterm prognosis. The Framinghan Heart Study demonstrated LVH was present in 15-20% of adults. It also suggested for each 50g/m2 increment of left ventricular mass the relative risk of cardiovascular disease increased by 1.73 in men and 2.12 in woman. Hypertension, obesity and valvular heart disease account for most causes of LVH. However, it is important to investigate patients with otherwise unexplained LVH since many causes are eminently treatable. Whilst there are several electrocardiograph (ECG) criteria for LVH they lack adequate sensitivity and specificity. Non-invasive transthoracic echocardiography (Echo) is easy, highly specific and can accurately measure the interventricular septal and posterior wall thickness. At the same time, it can characterise whether the hypertrophy is concentric or eccentric as seen in asymmetrical septal hypertrophy (ASH) in
hypertrophic cardiomyopathy (HCM). Also valve pathologies such as aortic stenosis are readily identified.
'BCSZEJTFBTF Of the rare disorders Fabryâ€™s disease is of particular interest as it is easily confirmed and is treatable. Up to 3% of males with unexplained LVH may have Fabry disease, an X-linked lysosomal storage disease due to deficiency of the enzyme alpha galactosidase A. Patients present with micorvascular disease of heart, kidneys and brain, resulting in death. Unlike many sex-link disorders this one can affect both genders although it is often less pronounced in women. The importance of diagnosis is that this disease is treatable. Otherwise progression of disease can lead to life threatening complications in adulthood. LVH (usually concentric) is a key feature to Fabry disease. It occurs in at least 50% of males and a third of females. Right ventricular hypertrophy is also common
Table 1: Common and rare causes of LVH. Hypertension : Echo concentric LVH Aortic stenosis: Echo estimate severity Obesity: Echo concentric LVH Physiological LVH Echo mild concentric LVH and dilated LV cavity athletic heart: Hypertrophic Echo: asymmetrical septal hypertrophy most common, with possible cardiomyopathy: dynamic LVH outflow tract obstructions. Genetics: autosomal dominant
Dr Mark Hands Clinical Associate Professor (UWA), Interventional Cardiologist
About the author Dr Mark Hands graduated from UWA with Honours and trained in Cardiology at Sir Charles Gairdner Hospital and Brigham Womenâ€™s Hospital, Harvard Medical School. He is an Interventional Cardiologist in private practice at Western Cardiology (Chairman) and Emeritus Consultant Cardiologist at SCGH. In addition to general and interventional cardiology and echocardiography, his special interests include investigation and treatment of acute and chronic ischaemic heart disease. Dr Handsâ€™ procedural skills include cardiac pacing, coronary angiography, angioplasty and stenting (via radial artery) in stable angina and acute coronary syndromes.
and may lead to dilatation. The most sensitive way to diagnose Fabry disease in unexplained LVH in males (unreliable in females) is to measure the alpha galactosidase A levels in blood leukocytes. There is now a kit available for dried blood spot enzyme assay. The importance of recognising Fabry disease lies in the availability of disease modifying enzyme replacement therapy. Clinical trials have demonstrated how treatment can reduce the risk of major clinical events, remodel the left ventricle, improve cardiac function and increase exercise tolerance. Extra cardiac benefits include stabilisation of renal function and improvement of peripheral pain. The best treatment outcomes have been obtained when treatment is started early. Therefore early diagnosis and screening relatives of confirmed cases are essential.
Myocardial infiltration disorders Amyloidosis: ECG low voltage, highly echogenic ventricular walls, thickened atrial septum and valves. Restrictive physiology. Haemochromatosis: ECG LVH. Echo LVH restrictive physiology. Genetics HFE gene testing (autosomal recessive). Left ventricular non Diagnosed by Echo. Familial (25%), triad of palpitation, thrombocompaction: embolism and heart failure. Metabolic disorders: Fabry disease, Pompe disease, Danon disease, PRKAG2 cardiomyopathy, Primary carnitine deficiency Mitochondrial eg. Kearns Sayre syndrome cardiomyopathies: Syndromic conditions : eg. Noonan syndrome, Friedreichâ€™s ataxia
QCardiac ultrasound showing increased left ventricular thickness (which can be due to hypertrophy or infiltration).
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Hot Topic of Ethical Super If we want a cool, green planet, then we need to look at ethical divestment of our money, says GP %S(FPSHF$SJTQ.
ivestment, if you have not heard the term already, entails the selling off of investments or assets for ethical, social or environmental, rather than purely financial, reasons. Used en masse, it is a powerful tool and credited as a key mechanism in the dissolution of apartheid in South Africa. It has also been effectively used against tobacco companies by some superannuation and other funds. Right now there is a similar and fast-growing movement occurring with regard to fossil fuel companies because of their role in the production of greenhouse gasses. And this is of special concern to doctors. The edict of ‘first do no harm’ is integral to our practice and philosophy in medicine, so it would be incongruous and contradictory to ignore the impacts of our actions beyond the consulting room. If it is morally wrong to do harm, then it must also be wrong to profit from that harm.
Climate change, driven by fossil fuel combustion and deforestation, has been widely recognised as the biggest threat to human health this century. We have seen its direct effects of extreme weather events, heatwaves and worsening air pollution; then there’s a range of indirect and complex environmental problems such as changing patterns of disease, food insecurity, decreasing freshwater availability and interruption of other vital ecosystem services. We are seeing ample evidence of these impacts at just 0.7C rise of average global temperature and these consequences are likely to escalate and eventually become unmanageable as temperatures increase. Estimates of between 160,000 and 400,000 people are dying each year due to climate change. Scientists have calculated the total amount of carbon (or carbon budget) that can be
burned which would allow average global temperatures to remain below a specific level. If the average temperature increases a further 2oC, this equates to an extra 580 gigatonnes. On the current projected use, this budget will be exhausted in less than 15 years. Fossil fuel companies currently have 2750gt, or more than five times this amount, as reserves on their books, but they are still searching for more. So, to avoid 2oC warming, most of these assets will need to stay buried in the ground. As the world inevitably starts taking climate action seriously, so these fossil reserves, coal especially, will become stranded assets and share prices in these resource companies will tumble. From a purely financial viewpoint divestment makes sense, from a moral one it is compelling. O
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Visit investec.com.au/medical or call your local ﬁnancial specialist on 08 9214 4500 to ﬁnd out how we can help.
Specialist Banking Home loans | Car ﬁnance | Transactional banking and overdrafts | Savings and deposits | Credit cards | Foreign exchange | Goodwill and practice purchase loans Commercial and industrial property ﬁnance | Equipment and ﬁt-out ﬁnance | SMSF lending and deposits The Investec credit card is issued by Investec Bank (Australia) Limited ABN 55 071 292 594 (Investec Bank) AFSL/Australian Credit Licence 234975. All ﬁnance is subject to our credit assessment criteria. Terms and conditions, fees and charges apply. We reserve the right to cease offering these products at any time without notice. You may cancel the account by writing to us within fourteen days of the date of our notiﬁcation to you conﬁrming that the account has been opened, without giving any reason and without paying any charges. Investec recommends that you seek independent tax advice in respect of the tax consequences (including fringe beneﬁts tax, and goods and services tax and income tax) arising from the use of this product or from participating in the Qantas Frequent Flyer program or from using any of the rewards or other available program facilities. *Qantas Points are earned in accordance with the Investec Qantas Rewards Program Terms and Conditions available at investec.com.au/cards. Points and bonus points are earned on eligible purchases only. You must be a member of the Qantas Frequent Flyer program in order to earn and redeem points. Qantas Points and membership are subject to the Qantas Frequent Flyer program Terms and Conditions available at qantas.com/terms. See deﬁnition of Eligible Transaction in the Investec Qantas Rewards Program Terms and Conditions, available at investec.com.au/cards.
Have You Heard?
#VEHFUVOTFUUMFT(1USBJOJOH In a media released headed ‘Rebuilding General Practice Training’, Health Minister Peter Dutton announced the closure of Health Workforce Australia, General Practice Education and Training Ltd (GPET) and Australian National Preventative Health Agency (ANPHA). In WA, WAGPET has been told its programs for GP training and education will continue to the end of 2015 with the exception of the PGPP Program. PGPPP will stop at the end of this year. After 2015 GP training will be put out to competitive tender. The state GPET chairs and CEOs were meeting on May 23 after Medical Forum went to press. We will report back in June on the outcome. GPET has raised the number of GP registrars in Australia from 400 to 1200 in 14 years.
Creditors, don’t hold your breath Some Perth practitioners and providers have been caught up in the collapse of General Practice Support Services (GPSS), which went into liquidation last year owing more than $6m to 100 creditors including wages, superannuation and annual leave to GPs. Recently GPSS was fined $22,176 by the Fair Work Ombudsman for underpaying staff. Medical Forum spoke to one of the administrators, Mr Robert Kite from Cor Cordis, who said it was impossible to single the Western Australian creditors from the list. He added that whoever they were, they would be waiting for a while as ‘recovery was a slow process’.
other health professionals tackling various health problems within a geographical area. GPs can be the main drivers of information that can include CPD and job information, and only accessed by registered health professionals (doctors have to log on). So far, HealthPathways is with two district health boards in NZ and has a consumer Health Information arm (http://healthinfo.org.nz/). Will they become defacto clinical guidelines? Keeping all up-to-date and relevant is important and a big task.
Pfizer eyes AstraZeneca The biggest USA drug maker Pfizer Inc has offered $124.5b for British pharma AstraZeneca (AZ), after the initial offer was rejected by the AZ board. The politics and figures behind all this are astounding. Analysts say AZ offers a pipeline of cancer drugs and tax and cost savings to Pfizer. The 2009 lecture by the NEJM ex-editor Dr Marcia Angell is thought-provoking (www. youtube.com/watch?v=uDbQNBla6aU) regarding the corporate pharma world. British politicians want to protect the investment AZ has in their country, and Pfizer’s CEO has reassured them. Four years ago Pfizer had decided to shut most of its research work at a R&D centre in southern England, where nearly 2000 jobs were reportedly lost. A hostile shareholder takeover is one option but the AZ share price is much healthier than a year ago and shareholders might want more cash in the combined cash-shares offer for the merged company.
Pharm and education
(1JOGPTIBSJOH Perth Central & East Metro Medicare Local will hold a Workshop for HealthPathways at the UWA Club on June 4-5. Primary Care Health Network co-lead Dr Mike Civil is involved. HealthPathways is developed in New Zealand (see www.streamliners.co.nz then, www.healthpathways.org.nz then, www. healthpathwayscommunity.org/ then, http:// wsproject.healthpathways.org.au/ and click on “Pathway Progress”). The idea appears to be centralised information adapted for local use. The idea is good – resource doctors and 12
On another pharma-related issue, untied financial sponsorship of medical meetings by pharmaceutical companies has become a key component of medical education funding in Australia with sponsoring companies averaging more than $200,000 each in such grants during the most recent reporting period. See www.medicinesaustralia.com.au
Adverse reactions reporting declines In the March edition we ran a story of a young woman who had a stroke while taking the oral contraceptive. We could not confirm that any of the doctors involved in her care had reported a possible adverse drug reaction (ADR). Like many others, maybe they were too busy or expect someone else to do the reporting. The NPS looks after the Adverse Medicine Events Line and our Medicines Line, both phone
reporting for consumers, and it makes no decision on whether a causal relationship is likely but leaves that to the TGA. Apparently, reporting directly by healthcare professionals to the TGA has declined.
4UBOEBSETVOEFSTDSVUJOZ The RACGP’s task of setting standards for general practice is not easy and will now be scrutinised. Our November 2013 survey of 147 GPs had a slim majority of GPs supporting the idea that accreditation maintained quality of health care (Yes 26%, Maybe 31%), but only a minority agreed that “the majority of things required of general practices undergoing accreditation are appropriately targeted to improve the quality of patient care” (Yes 31%, Uncertain 16%). In fact, 52% said they were being asked to comply with accreditation requirements that did not help. While 75% of general practices undergo accreditation, the Australian National Audit Office found that the ‘carrot’ of PIP payments cast doubt over measures of quality assurance. For this reason, the RACGP and the Australian Commission on Safety and Quality in Health Care has been asked to develop a governance and reporting framework for general practice accreditation in Australia (ends 2015) looking at complaint handling (e.g. duplications, variations in responses), what works and improve coordination (including an appeals mechanism). Current 4th edition standards are unaffected. O
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Informality Breeds Excellence From a hesitant start in medicine in the UK, Dr Ann Lewis’s experiences in Western Australia have encouraged her to tackle some big medical challenges head on. accident, Ann Lewis became another statistic.
Dr Ann Lewis isn’t completely comfortable with the notion that she’s ‘blazed a trail’. Nonetheless, it’s been an interesting career trajectory from a young doctor lacking confidence to a medico commended by her peers who really hit her straps in obstetrics and who now sings the praises of information technology.
“I ended up in RPH with a fractured ulna and a medial malleolus that needed screwing back together. It was my first substantial experience as a patient and I ended up on a four-bed ward with two loud and demented patients. It was awful! And it’s amazing how vulnerable it makes you feel.”
“I was very under-confident early in my career and found the entire process daunting and stressful. I could easily have decided that medicine wasn’t the career for me,” the 56 year-old GP Obstetrician told Medical Forum from her rooms in Kalamunda.
“It doesn’t reflect badly on RPH because it’s ICU and that’s where you need to be. I went on to Bethesda and that was a brilliant experience. Nonetheless, it was an interesting time. I was in a wheelchair for six weeks and people would direct their questions to the person pushing me. It’s as though you’ve lost your mind. The whole thing has made me more compassionate towards people in similar situations.”
Ann very nearly didn’t do medicine at all. She was heading for a more conservative and, at the time, gender-appropriate career of nursing.
“But I did well academically and my physics teacher said, why don’t you do medicine? It hadn’t even occurred to me. I trained in London, had twins – a boy and a girl – and did my GP training in Cornwall. I also did some obstetrics and psychiatry training and then came to Australia in 1991.”
Ann’s daughter Chloe followed her mother’s footsteps into medicine. She was a resident at SCGH and is currently in the US doing a Masters in Public Health and working with medical device companies in Silicon Valley.
Halls Creek here I come After her first 12 months on the Central Coast of NSW at Gosford, Ann found herself at Halls Creek, thoroughly acclimatised to the informality of Australia, which she said suited her well. Anne reaffirms the positives of remote medicine and its inherent benefits in the development of professional skills. She also reflects on different aspects of the urban/ rural divide. “Halls Creek was a fascinating and wonderful time. It’s a different country out there and I was seeing things like rheumatic fever, endstage kidney disease and leprosy. You don’t have the luxury of back-up and investigative
I was in a wheelchair for six weeks and people would direct their questions to the person pushing me. It’s as though you’ve lost your mind. The whole thing has made me more compassionate towards people in similar situations.
options and it made me take responsibility for my decisions.” “The longest time in one place was the 10 years I spent at Narrogin from 2003. That was a fantastic and rewarding experience but demanding nonetheless. It’s difficult not to make yourself available virtually all the time and that can be stressful. The obstetrics there was wonderful and a definite high point was going back to KEMH in 2010 and developing skills in caesarean section.” “Dr Anne Karczub helped me enormously and it was one of the best things I ever did. It stretched me professionally and I loved it! The manual side was wonderful and made me feel like a proper procedural doctor.” “Having come back to urban medicine I do miss the personal familiarity of a small rural community. But it’s a more specific and self-contained role that I have now with the reassuring knowledge of plenty of clinical backup.”
“There’s been amazing changes in the training of doctors. There’s much more access to information, that’s definitely been democratised, and the supervision is a lot better than it was in the past.” “In the UK when I went through medical school, it was top-driven from the consultant down, it was pretty much sink-or-swim and quite easy to slip through the net. There’s a lot more care and support now for young doctors. I’m really impressed with the residents I see at Bentley. They’re switched on and much more confident than I was at the same stage.” Ann thinks the development of IT and social media is good news for medicine. “I’ve only written five tweets in my entire life but I’ve done some work at Bunbury ED and they’ve been pioneers of the whole social media in medical education area. They create and share free podcasts so it’s a real democratic sharing of information.” Ann is now working at Bentley Hospital one day and Mead Medical three days a week, and a weekend every month doing obstetrics at Bentley.O
'SPNBQBUJFOUQFSTQFDUJWF An increasing trend for West Australian holiday-makers is their Bali adventure ending in tears. In July 2013, after a motor-bike
By Mr Peter McClelland
X Prof Osvaldo Almeida, Director of Research at the WA Centre for Health and Ageing and Chair of Old Age Psychiatry at UWA was awarded the Senior Research Award by the Royal Australian and New Zealand College of Psychiatrists at its annual conference in Perth, last month. X Mandurah GP Dr Frank Jones has nominated for the presidency of the RACGP. He is currently vice president. He will contest next month’s election against Queensland GP Dr Evan Ackermann. Voting opens on June 14, and the winner will be announced on 14 July.
X Prof Geoff Laurent is the new director of the Lung Institute of WA. Professor Laurent will continue on as director of the Centre for Cell Therapy and Regenerative Medicine (CCTRM) at UWA.
X Mr Christopher How has been appointed as the new CEO of Bethanie, after acting in the position while the board conducted an executive research. Mr How began his career with Bethanie in 1990 as a registered nurse.
X Prof Andrew Whitehouse, head of development disorders research group at the Telethon Kids Institute, has been made patron of the Kids are Kids Therapy and Education Centre.
X The chair of HealthEngine, Mr Patrick O’Sullivan, has been appointed to the board of internet service provider, iiNet.
X Lifeline WA has appointed five new board members. Qube property Group MD Mr Mark Hector, Emeco Holdings CEO Mr Ken Lewsey, Department of Transport DG Mr Reece Waldock, PPR GM Ms Nicole Moody and Quickboats marketing director Ms Nicole Walton all take their seats. NAB’s Mr Wayne Rimmer has stepped down. The board continues to be chaired by Mr Brett Goodridge and Ms Fiona Kalaf remains CEO.
X Kimberley doctor Dr Rob Phair has been appointed to the Board of ACRRM as its Western Australia director. His new role will continue until October this year. X Prof Simon Willcock will replace A/Prof Stuart Boland as Chair of Avant Mutual Group Limited on June 30.
X The purchase of Mercy Hospital Mt Lawley by St John of God Health Care (SJGHC) has been approved by regulators and settlement took place last month. Ms Chris Hanna has been appointed CEO of the hospital, which will now been known as St John of God Mt Lawley,
X Dr Marion Davies has been appointed JuMP Rural Committee Member at Rural Doctors’ Association of Australia
X Prof Markus Melloh has taken up a residency at the Zurich University of Applied Science. He is still working as an adjunct professor at UWA and Curtin University. X Assist/Prof Gabrielle Brand, Prof Christopher Etherton-Beer, A/Prof Rosemary Saunders and A/Prof Helen Dugmore have won a WA Nurses Memorial Centre Charitable Trust grant to explore and evaluate the use of photographs as a teaching and learning tool for UWA medical and nursing students. X The Genetic Support Council WA has won a $1.2m DoH contract to provide statewide support and information services to the community on a range of rare diseases.
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Finance Takes a Leaf Out of Medicine Your ﬁnancial planner is like a doctor. Hold back on crucial information and the treatment might not go so well. across the professional spectrum. Most of us tend to go with the status quo.”
The decisions we make regarding our superannuation portfolios are more complex than we realise. Professor Paul Gerrans from the UWA Business School suggests from his experience that doctors, who often work in high-risk environments, may approach their financial investments more conservatively than is necessary. And he has some interesting things to say about cognitive decline and the repercussions on Self-Managed Super Funds.
Doctors are firmly positioned in a high networth bracket within a broader, high status demographic. Nonetheless, it is undeniably stressful at times and carries some degree of professional risk. Given this, might there be some indication as to their inherent style of financial decision-making? “Extrapolating from their professional background there may well be a tendency for doctors to head in a certain direction. This revolves around the specific level of ‘background risk’. If an individual is involved in what is deemed to be a ‘high risk’ sector you might reasonably expect them to seek out a compensatory lower risk strategy in their financial planning.”
“My initial interest in retirement savings began with UniSuper [University Superannuation Scheme] in 1998. Members were offered a significant choice – whether to move from a defined benefit into a defined contribution scheme.” “Some people made choices that didn’t make a lot of sense, and these were individuals who were on quite high incomes at a relatively young age. They opted to make that move even though they were transferring to a scheme with increased risk to themselves, the employee.” “I was struck by how people actually came to a decision and interested in what sort of
Q Prof Paul Gerrans, UWA Business School
information they were relying on. That started the ball rolling for me and I’ve been looking at individual choice with a particular interest in retirement savings.” “The overarching thing is that people tend to run with the flow and it seems fairly pervasive
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Another area worth considering, and one with a strong affinity with the medical consult, is the nature of the client/adviser relationship and the critically important issue of disclosure. “One area we’ve looked at is a person’s level of embarrassment or fear in relation to their current situation. They may be frightened of Continued on P20
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Super Tips to Consider Superannuation can be a shifting landscape and there are tricks of the trade to keep one step ahead. The world of finance is a complex one and, like many patients, difficult to fully comprehend. Medical Forum spoke with some local superannuation advisers to highlight areas of interest for medical professionals as tax times looms. GESB is WAâ€™s largest superannuation provider with in excess of $17 billion in funds under management, overseeing the management of retirement savings in the WA public sector for more than 70 years. Taking a proactive approach is critically important, according to a GESB spokesperson. t 8IFSFJTZPVS4VQFS *GZPVWFIBENVMUJQMF employers you may have a few different Super funds. Consolidating your funds into a single account makes it easier to manage and youâ€™ll save on fees and charges. t $IFDLZPVS'FFT"TNBMMEJÄŒFSFODFJOGFFT can mean a large variation in total retirement savings. You may not need those extra features that a more expensive fund provides. Know what youâ€™re paying for! t 1SPUFDU:0634&-'.PTU4VQFSGVOET provide a default Insurance Cover when you join. Using a fund in this way can be a costeffective way to protect both you and your
family. Premiums are paid directly from your Super and, in some cases, the premiums are tax deductible. t "EEJOHUPUIF1PU:PVSFNQMPZFST contributions may not be enough. Salary sacrifice can be an effective way to increase the size of the fund. Peter Allen, from Lifespan Financial Planning, focuses his attention on Concessional and NonConcessional Caps on superannuation. He said it was expected that indexation of concessional contributions caps will continue in 2014-15. It is important to review salary sacrifice arrangements and increase the amount if appropriate. This is especially relevant for those between the ages of 49-59 on 30 June 2014 given that their cap will rise by $10,000-$35,000 for 2014-15. For those with significant sums to invest it may be beneficial to delay the â€˜bring forwardâ€™ provisions until 2014-15 to take advantage of the non-concessional cap. By contributing $150,000 this current financial year and $450,000 in 2014-15, clients can make nonconcessional contributions up to $600,000 over a short period of time. However, no further non-concessional contributions can be made for the next three years.
Peter says self-employed doctors with some income from public hospitals â€“ if their employed income (including reportable fringe benefits and employer super contributions) exceeds 10% of their total income, it makes them ineligible for concessional contributions. Les Conceiaco, Senior Financial Adviser with Morgans Financial draws attention to some key superannuation changes that will become effective from July 2014. t $POUSJCVUJPOT$BQÄ‡FSFIBWFCFFO increases in the Concessional (Pre-Tax) and Non-Concessional (Post-Tax) Contributions Cap with the actual figures varying according to age-bracket. And, subject to legislation, the Superannuation Guarantee Contribution rate will increase to 9.50%. t Ä‡FPVUMPPLGPSNPTUFDPOPNJFTJT generally positive and, after an expected softer result in the next quarter, the US economy appears to be on track to stronger recovery over the next 12 months. This will result in commensurate share-market growth and a stronger US dollar. ED: All the above information is of a general nature only. Individuals should seek professional financial advice to ensure they meet their particular needs and objectives.
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Finance Takes a Leaf Out of Medicine whatâ€™s in store and the steps that might be needed to rectify it. So the big question here is disclosure, the extent to which an individual might withhold certain things.â€? â€œItâ€™s a given that the delegation of responsibility ultimately relies on a full exchange of information. If that doesnâ€™t happen it will weaken the relationship and, in fact, itâ€™s one of the key aspects of being a financial adviser.â€? â€œIf they feel that theyâ€™re not getting the complete picture theyâ€™re bound to provide a disclosure to the client that they must consider their broader circumstances before acting on any financial advice. The confidence within the relationship needs to flow both ways otherwise the quality of the information canâ€™t be assumed.â€? â€œWe actually borrowed this patterning of information exchange from the world of medicine. Thereâ€™s an established medical scale teasing out issues surrounding anxiety levels linked with both disclosure and/or evaluation. Weâ€™ve taken research from a medical model and weâ€™re using it in the financial sector.â€? A consideration of financial literacy inverts the dynamic of relationship â€˜anxietyâ€™. In this instance it may well be the alpha-personality medical professional who needs support. â€œThereâ€™s often an incorrect assumption that everyone is able to develop a capacity to be financially literate. Itâ€™s interesting to see how people contract that out. Who do people delegate to? How successful is it?â€? â€œFor some people the anxiety engendered by delegating that advice may prevent them seeking it in the first place.â€?
Another of Paulâ€™s research interests is financial decision making within the context of cognitive decline. This can be a tricky area, a tangled web of impaired intellect, family dynamics and individual greed. â€œWe now have a greater proportion of people with significant assets and there are important considerations for their later years. Particularly with Self-Managed Super Funds (SMSF) more work needs to be done on the relative evidence of decline and the types of decisions individuals are making.â€? â€œIt needs to be a lot more context specific than â€˜people with cognitive decline perform poorly on financial literacy tests.â€™ There needs to be some applied research that will provide more accurate measures of judgement and then weâ€™ll be able to draw a more effective link between the two.â€? Paul stresses the importance of the adviser/ client relationship and the fact that the landscape of superannuation itself is often depicted in more complex terms than is actually warranted. â€œThe interaction is dynamic, it changes over time. And thereâ€™s always a balance, from the clientâ€™s point of view, between trying to make assessments regarding the technical expertise of the adviser and the perception of the person themselves â€“ whether he/she is a â€˜niceâ€™ person?â€? â€œItâ€™s interesting to think about how and why a level of confidence develops that leads to the client feeling theyâ€™re going to get a good outcome. In one sense, perhaps the investment industry is its own worst enemy. At times they can create a sense of complexity and change that is more acute than is actually the case.
Les Conceicao (MBA MIR BA Grad Dip FP FFin AFP)
Senior Financial Adviser Authorised Representative 296710
08 6462 1999 | www.morgans.com.au/perth Level 20, 140 St Georges Tce Perth WA 6000
There will always be change but itâ€™s over-egged at times.â€? Finally, Paul makes some broader points regarding superannuation. â€œI think thereâ€™s a somewhat entrenched view that Super is set apart from a broader portfolio. Itâ€™s never a good thing to rely on just one particular investment vehicle and it should be one of a range of products that an individual has in their portfolio.â€? O
By Mr Peter McClelland
5",&)0.&10*/54 t A#BDLHSPVOESJTLNBZXFMMCFBGBDUPS in decision making. t 'VMMEJTDMPTVSFJOBDMJFOUBEWJTFS relationship is critical. t $POmEFODFBOEUSVTUOFFETUPnPX both ways. t 'JOBODJBMABOYJFUZOFFETUPCF acknowledged and taken into consideration. t 4VQFSBOOVBUJPOJTOPUBMXBZTBT DPNQMFYBTJUTFFNT
GESB Award Winning Financial Adviser Les has over 14 years experience as a licensed ďŹ nancial adviser with over 5 years as a Senior Financial Adviser with GESB Financial Advice and is a multiple award winner of the GESB Financial Adviser of the Year. Les has specialised knowledge to create tailored tax-effective strategies to maximise your beneďŹ ts from: Âƒ GESB West State Super Âƒ GESB Gold State Super
Additionally, Morgans offers the Wealth+SMSF Solution service which frees up your time by taking care of the establishment and complete administration of a SMSF. We also offer top class equities and securities research, enabling comprehensive management of your SMSF portfolio. To make an appointment or discuss your needs, please call Les on 08 6462 1960.
Morgans and CIMB â€“ Please visit www.morgans.com.au to understand the products and services within our alliance. RBS Morgans Limited ABN 49 010 669 726 AFSL 235410 A Participant of ASX Group. A Professional Partner of the Financial Planning Association of Australia
Finance Education for Doctors
• A business school level ﬁnance course for doctors • Learn how ﬁnance and investing works with Associate Professor Sam Wylie
25 doctors are currently taking the ﬁrst course “Fantastic course – worth its weight in gold.” Dr S. Jeganathan
The second course commences Saturday 26 July, 9:30am – 12:30pm for 10 weekly sessions
Register interest or enrol at
www.windlestone.com.au or call 0413 402 556
A fundamental topic in ﬁnance is covered each week to build up a complete framework for making ﬁnancial decisions about personal wealth management and medical practice management. The course is taught in the business school style of theory mixed with practical cases. No prior knowledge of ﬁnance is assumed.
Finance for Doctors course: 9:30am – 12:30pm Saturday morning for 10 weeks, beginning 26 July 2014 Where: The Law Lecture Theatre 1st Floor, Law Building University of Western Australia
Dr Sam Wylie is an Associate Professor of the University of Melbourne and 5 times the winner of Melbourne Business School’s Teaching Excellence Award. From 1997-2004 he was an Assistant Professor of Finance at the Tuck School of Business at Dartmouth. He undertook his PhD at the London Business School from 1992-1996.
Windlestone Education does not hold an Australian Financial Services Licence and does not provide ﬁnancial advice of any kind. Windlestone Education is a provider of education services only. Windlestone Education is not afﬁliated with either the University of Western Australia or the University of Melbourne.
Battling Diabetes in the Bush Carnarvon medicos and health workers are fighting diabetes with both hands tied behind their backs. The Aboriginal Medical Service (AMS) in Carnarvon has 340 diabetic patients on its books, which poses a real challenge for people like Diabetes Educator Patricia (Nola) Councillor and Dr Nigel Brennan. “We cover a wide area providing primary and secondary health care. For example, I travel to Gascoyne Junction which is 170km away to check BSLs, BPs and provide advice on diets for patients with diabetes,” said Nola. “It’s a big job as I don’t have any support staff and it’s pretty difficult to get them to come in to see us.” Nola, an Aboriginal woman born in Mullewa who has lived most of her life in the Murchison area, is convinced that education is the cornerstone in addressing the serious ramifications of diabetes. “I’m always trying to make people more aware of the full impact of this disease and what it’s doing to them on the inside, all those things they can’t see. These are my ‘blood people’ and it makes me sad because all I can see is them ending up on dialysis
or dying. And some of these people are men and women in their 30s and 40s.” “So much of this problem is about taking control of lifestyles. There’s alcohol, smoking and diet involved and I find it very frustrating. Sometime I look at the situation and I think, ‘what the hell am I doing here?’.”
/FFEGPSHSFBUFSUFBNXPSL And Nola’s frustration is not confined to those individuals who forget to monitor their glucose levels. It would seem, on a broader institutional level, there’s room for improvement. “I’ve been working with Diabetes WA (DWA) and invited them to come to Carnarvon and speak at a breakfast seminar. I’d hoped that all the relevant local service providers would come along but only five people turned up. That response made me sad. For DWA to come all this way it was disappointing for them. It’s time for everyone to work together as a team.” Nola’s diabetic patients and their treatment is the sharp end of remote medicine with all its attendant difficulties.
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Q Dr Nigel Brennan and, above, a well-ventilated Murchison waiting room.
“Some of these people live a long way away and they need a lot of support and encouragement. They have to know their sugar levels but they need support and encouragement to ensure they monitor their readings. It’s hard for some of them and I’m always hearing ‘oh, I forgot’.” Nola provides a practical example that sums up the dilemmas faced by both clinicians and patients attempting to deal with diabetes in a remote setting.
Lack or resources “We don’t have dialysis machines in Carnarvon and some of our people say, ‘I don’t want to go to Perth… it’s not my country’. There’s an elder in our community who refuses to go to Geraldton and that’s sad because he needs more advanced treatment.” “The Gascoyne region has missed out on funding probably because we’re squeezed between the Kimberley and the Pilbara. When you factor in issues such as alcohol abuse I don’t see the situation improving much, quite frankly.” Dr Nigel Brennan is the SMO at the Carnarvon Aboriginal Medical Service. The former UK ED surgeon has a plethora of experience working in disadvantaged communities both in Australia and overseas. “I’ve never been one for only treating a mainstream, ‘worried well’ population. My wife and I volunteered to work in Tonga and I was the only doctor on the island seeing everyone from royalty to the very poor. Then I went to Yeppoon in northern Queensland as a GP. I treated an Aboriginal elder and suddenly I had 194 indigenous patients on my books.”
A depth of experience is required, says Nigel, to come to terms with the challenges of indigenous rural medicine. “I did nine months in AMS at Port Hedland and I’ve been here for just over a year. I love the medicine but the politics can be quite challenging, even for an oldie like me.” [Nigel is 62 years-old.] “I wouldn’t want to be a young doctor out here because some of the decisions require a lot of experience. It’s not the sort of place where you can be gung-ho! Aboriginal health is so out of the box and it’s interesting to note that just 0.7% of GPs look after 95% of indigenous Australians.” “The unsung hero is [Geraldton surgeon] Dr Charlie Greenfield. He’s been coming up here for years, has an amazing memory for individual patients and is a stalwart supporter of Aboriginal medicine.”
Mortality vs morbidity Nigel, like Nola, believes there’s a long way to go before significant improvements begin to materialise. “I don’t think anything’s made a significant difference in relation to diabetes. We’re not making inroads into overall mortality but we are in terms of morbidity – we’re stopping bits dropping off!” “As Nola says, we don’t have dialysis facilities in Carnarvon. And if we don’t get welltrained staff we never will! But, given some
Q It’s along way from anywhere!
of the patients with their deteriorating renal condition, it’s a stick I can use to persuade them to change their lifestyle. I ask them if they’ve been looking around to buy a house in Geraldton and they look at me as if I’m an idiot. And then I tell them that they’ll be living there soon because their kidneys are packing up.” “They love country and don’t want to hear that. And some of the younger patients have seen elders leave for dialysis and never come back.” Balancing the books is an integral part of a well-oiled health service and for an AMS where funds have to work harder, Nigel says Carnarvon has cause for celebration.
“My wife is the Medical Manager and she’s very good at getting unclaimed money back from Medicare. If there’s a mistake in the paperwork, they won’t pay the invoice and there are some cases going back four years. We’ve managed to get back six-figure sums.” “But in terms of making a difference to health outcomes I think the way forward is to have more trained Aboriginal health workers working in conjunction with experienced doctors.” O
By Mr Peter McClelland
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Building on healthy foundations.
On Monday 5 May the ownership of Mercy Hospital Mount Lawley was transferred from MercyCare to St John of God Health Care. Now renamed St John of God Mt Lawley Hospital, the acquisition will enable St John of God Health Care to develop more integrated health care systems across metropolitan Perth. We aim to build on the rich tradition of the Sisters of Mercy in meeting the future health care needs of the community. To achieve this we will invest in: Expanding and enhancing existing hospital facilities Continuing the hospitalâ€™s proud tradition of excellent obstetric care Developing already strong rehabilitation services Maintaining and improving other medical and surgical specialities This will ensure a contemporary, hospitable patient experience, a great work environment and quality equipment for medical specialists. Our growth in Perth also enhances our capacity in clinical education, research, and training the future medical workforce.
For more information visit www.sjog.org.au/mtlawley
Hospitality I Compassion I Respect I Justice I Excellence
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Central Referral Service Speedier more equitable access to specialists in public hospitals is behind the new CRS. How well designed and implemented is the new system? Public hospitals are facing demand that outstrips their clinical services. Some say doing things smarter is the key. More overseas-trained doctors and a more mobile national workforce mean the usual referral networks amongst â€˜localsâ€™ are falling down. DoH launched the Central Referral Service (CRS) in February as part solution. The idea is to triage referrals to specialists in public metropolitan hospitals, or as they say â€œright care, right place, right timeâ€?. This includes better use of non-tertiary hospitals.
could not save into patient records any pdf form with predetermined fields, once it had been completed.
No clinical triage is attempted by CRS. Instead, they assess if there is enough information in the referral for the clinician to assess urgency. This is not simple. For example, a few years back about 40% of PMH referrals were judged incorrect â€“ most needed to be redirected to another service and others lacked important information and went back to the referrer (e.g. weight and height not given for a â€˜failure to thriveâ€™ referral).
Assuming a referring GP is ignorant of referral possibilities, he or she would ideally like to click on a referral form (downloaded into their clinical software), load patient data, add notes for this particular referral, and send it electronically before saving into the patient notes. Progress reports from the hospital would arrive electronically. The GP would like this for anyone going into the public system, for the first time, for any reason, acute or not. However, while the Step-by-step guide to using Central Referral Service confirms it is for any â€œfirst outpatient appointment with a specialist at a clinic within a public metropolitan hospitalâ€?, it then lists things the service will NOT handle: t *NNFEJBUFSFWJFXT XJUIJOOFYUTFWFO days) t .FOUBM)FBMUISFGFSSBMT t /PONFUSPQPMJUBOPVUQBUJFOUDMJOJDT t "MMJFE)FBMUIPVUQBUJFOUTFSWJDFT t /POEPDUPSMFEPVUQBUJFOUTFSWJDFT VTFST are referred to a list). t 3FGFSSBMTGPSUIF"NCVMBUPSZ4VSHFSZ Initiative (that is, low-risk patients seen privately at a non-teaching hospital outpatients for endoscopy, cataract removal, cystoscopy, minor gynae/general surgery). t "MMSFGFSSBMTGPSPCTUFUSJDBMQSPCMFNT (including KEMH) â€“ a late withdrawal, to minimise clinical risk for pregnant women during CRS start-up. The website could be more user friendly (www.gp.health.wa.gov.au/crs/about/refferalforms.cfm) and it took eight minutes to fill out, in a rudimentary way, one of the five-page downloadable pdf referral forms. If you have Best Practice or Medical Director software, template forms can be downloaded and incorporated in your desktop software. One major practice using MedRecord32 has had to do their own templates and said they medicalforum
What happens after referral? Remember, CRS is only for non-urgent referrals. â€œClinical Priority Access Nursesâ€? will decide how the referral from the specialist, or GP, or remote nurse practitioner matches available resources within the public health system â€“ by comparing hospital, specialist expertise and availability, service required, and time to be seen.
What health consumers are told Consumers are told CRS is more efficient than redirection of an incorrect referral. So now the referring doctor need not select anyone or anywhere to refer to. â€œThe GP will no longer need to choose a specialist [but] where appropriate the CRS will take any preferences into account.â€? And then there are geographical boundaries: â€œValid justification will need to be provided by the referrer if requesting a patient to be seen by a named specialist that is out of catchment.â€? Rural doctors are possibly an exception, as CRS has said it will accept referrals from WACHS doctors or nurse practitioners. In fact, CRS will honour crossboundary referrals by GPs if their justification for using a particular specialist is appropriate. â€œCRS will also allow WA Health to be more responsive to community needs, increasing accountability and communicationâ€?, their website explains. Live the dream! We are not sure how the CRS caters for the community doctor who is already doing a splendid job using established networks within WA â€“ will things improve for them and their patients? The spokesperson for the Health Department explained: â€œWhilst
the CRS continues to direct named referrals to public hospital specialists, the CRS provides two points of standardised referral acknowledgement to the referrer and an enhanced audit trail. As such, referrers are better informed regarding a patientâ€™s referral status.â€?
What of the future? The CRS will accept referrals via fax, postal mail and electronically via mMex â€“ fax is preferred! The aim is to transition to bidirectional secure electronic outpatient referral pathways in time. There is a place to identify on the referral if â€œthe patient is suitable for Telehealth consult. Once operational, the CRS plans to work with Telehealth toâ€Śincrease uptake of this service.â€? The referral form contains mandatory fields for a referral to be accepted â€“ you just need to check the minimum criteria list in the â€˜information for referrersâ€™ because mandatory fields are not listed on the form! Some GPs are already encountering returned rejected referrals.
What about acute referrals and feedback? The Clinical Priority Access Criteria (CPAC) Referral Guidelines will continue to be available on the GP Website. â€œReferrers should review these to support their referral decision.â€? the website says. CRS feedback consists of an automated fax when the referral is received by CRS and again later, if the hospital accepts the referral. The hospital will advise patients directly when their outpatient appointment is made. We know of no hotline for the patient to ring CRS and cancel their appointment (should the problem resolve, be treated privately, or other circumstances intervene, as happened often with the Waitlist Bureau). Instead, we understand this is handled by each hospital. However, doctors can contact CRS on 1300 551 142 or email email@example.com if they have any questions. O
By Dr Rob McEvoy
We would like to hear of your encounters with CRS, good or bad. Leave a message at: medicalhub.com.au or email: firstname.lastname@example.org. 25
Telehealth: Good Medicine, Tricky Politics If the future is telehealth as politicians espouse, many are wondering in this era of cost-cutting when it will become a reality. At last Novemberâ€™s WA Health Conference, the Health Minister, Dr Kim Hames, was singing the praises of telehealth â€“ citing the Ontario model, a Canadian state with similiar geography and demography as WA â€“ as a solution to a whole range of access problems to health care in the state. A study of the biggest telehealth provider in Ontario â€“ the Ontario Telemedicine Network (OTN) â€“ shows that from its small beginnings in 1997, it now has four channels of virtual care: t "NCVMBUPSZ$BSF XIJDIJOTBXPWFS 300,000 provider/patient real-time video consultations in over 40 specialty services. t "DVUF$BSFXBTTVQQPSUFECZUFMFTUSPLF (for tPA), acute burn, crisis psychiatry, trauma, critical care, and long-term care. t &EVDBUJPODIBOOFMTTBX WJSUVBM education events for over 400,000 in 2013. t $ISPOJD%JTFBTF.BOBHFNFOUJO patientsâ€™ home. [No figures supplied, though â€˜Substantial reductions in hospitalisation and emergency room visitsâ€™, cited]. Little wonder it has local politicians and
health bureaucrats sitting up and taking notice.
ended up spinning off a Pty Ltd company and gave away 10,000 of the 10,002 shares to set up a disability, disadvantage and philanthropy trust.â€?
For one WA start-up telehealth company, FibreMed, founded by infectious diseases specialist Dr Michael Watson, the clinical results are promising.
â€œThe lack of specialist clinical services in registered aged care facilities (RACF) was the other area of need where we believed telehealth could bring real benefits. From my own clinical experience, I would discharge elderly patients from hospital and it was impossible for me to follow them up.â€?
He started FibreMed about three years ago after a visit to the Kimberley with ENT surgeons Dr Richard Lewis and Dr Steve Rodrigues. The trio discussed telehealth with the Kimberley Aboriginal Medical Services Council as a way of delivering continuity of care. By consulting and up-skilling local GPs, Aboriginal health workers and remote area nurses via telehealth, ear health in young children has started to improve. Q Dr Michael Watson
â€œI realised then that you canâ€™t do telehealth well as a small-scale operation. It has to be well-organised, with sound IT, legal and business infrastructure,â€? Michael said. â€œI
â€œSo using the same infrastructure and technology, FibreMed collaborated with four of the major RACF groups â€“ Bethanie, Amana Living, Juniper and Bapistcare. We work closely with Dr Scott Blackwell. What heâ€™s doing with Nurse Practitioners (NPs) in RACFs is a real success story. Governance is with the GP but the NPs do a lot of the dayto-day management.â€? â€œWe have integrated telehealth into that model so NPs in RACFs, who know the patients well, work with GPs and specialists. They consult and oversee treatment, while NPs manage the scripts, pathology and follow-up. We have just started working with
geriatrician Dr John Kitchin who is working with complex patients.”
Positive patient experience “We are finding patients, even with mild cognitive impairment, relate extremely well to telehealth. That was a surprise and so, too, was the level of rapport you can establish through video.” Michael said telehealth also offered practical knowledge spread as well. “NPs learn really quickly because they are part of the consult and this in turn can reduce the number of telehealth consults as they pick up skills. This sharing of specialist skills in primary care is a major benefit.” However, politics and payments are jeopardising FibreMed’s capacity to grow and may even threaten its existence. Even before last month’s Federal budget, things were looking tough.
4VSWJWJOHUIFGVOEJOHDSJTJT Three years ago, the Federal Labor Government introduced incentive payments for telehealth but the program was being rolled back by the last election. After shelling out for his own IT infrastructure, Michael has been struggling to cover costs. “FibreMed is like a service agency. We provide all the equipment and take a percentage, but I can’t charge enough from the distal end to make it work. Without an incentive payment at our end, it will be
Q How teleheath works in an aged-care setting.
almost impossible to break even. So we’ve hit crunch time now. We’ve got until June 30 to try and turn this around otherwise the revenue stream from Medicare billings will never allow this to work.” Despite the precarious financial position, RACFs have embraced telehealth. Michael says he has 16 sites and one has committed to continue the service out of its own pocket. But most sites don’t have the money to continue and Michael has been forced to stop expanding. Added to the Medicare issues, there have also
been changes in small business tax law which have had an impact. “Labor introduced immediate tax write-offs for assets worth $6000, so I was charging RACFs cost price and then I could write off the equipment as I required it, so in terms of cash-flow, it was even – there wasn’t a substantial financial liability.” “That rate has since been cut so now I have to charge them about 30% above cost price, which means clients can’t be covered under the incentive payment and have to fork out money themselves, which they don’t have, Continued on P29
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To Help You Work in ACFs Medical Forum asked Dr Elena Monaco to cast her experienced eye over a new guide produced by the RACGP â€“ she gave a cautious thumbs up. The RACGP has recently launched the Best Practice Guide for Collaborative Care between General Practitioners and Residential Aged Care Facilities. As the profession is trying to attract doctors into aged care (before they retire) we wondered how the college was helping. We asked Dr Elena Monaco to take a look. Elena did 10 years at Mt Henry Hospital and 10 years in psychogeriatrics at Fremantle Hospital as a background to entering aged care, so she is no novice to the task. â€œI believe the guide is aimed at the novice,â€? she said. â€œMost of us â€˜old handsâ€™ have it covered but having mentored doctors into aged care to help them establish Q Dr Elena Monaco these good practices, I would recommend this Guide as a good start.â€? She said claims that the Guide covers particular areas are true, albeit superficially. She refers to eight specific areas: t "DDFTTUPDMJOJDBMDBSFBOENFEJDBM records t 1SPUPDPMTGPSSFGFSSBMBSSBOHFNFOUT t $PNNVOJDBUJPOQSPUPDPMT
t .FEJDBUJPONBOBHFNFOU t 1BUIPMPHZBOEJNBHJOH t "Ä™FSIPVSTDBSFBOEFNFSHFODZ medicine t 3FNVOFSBUJPOGPSOPO.#4 reimbursed work t 0OHPJOHSFWJFXPGDPMMBCPSBUJPOBOE quality assurance The Guide was developed by the RACGPâ€™s National Standing Committee for General Practice Advocacy and Support (NSCGPAS) and aims to offer older people living in RACFs access to safe, high quality, coordinated and timely care. The college says it is pitched at GPs, general practice staff and RACF staff, focussing on collaborative arrangements, and is designed to be used in conjunction with the RACGPâ€™s Medical Care of Older Persons in Residential Aged Care Facilities (silver book). â€œI think it is useful in making GPs aware of what their obligations and rights are in RACFs. It suggests the GP should be local and have a few patients in the RACF rather than one in a variety of facilities, which is very pertinent. Having just one patient is very inefficient and unfair to the patient as it is unlikely their GP will visit regularly,â€? Elena said. â€œMany GPs feel obliged to keep their patients when they move to nursing homes and then canâ€™t deliver appropriate care. When one of my patients transfers to a nursing home out
of my area, I advise them that it is in their best interests to get a doctor in the area. I restrict my practice to an 8km radius from my home.â€? Her main misgiving is around hospitalisation. â€œI donâ€™t like the Guide spelling out indications for hospital assessment â€“ we now have the Residential Care Line nurses and Silver Chain Priority response that can help with many acute situations. I donâ€™t like my patients being sent for hospital assessment without it being discussed with me first, day or night.â€? She thinks the Collaborative Care Information Form is excellent because it spells out the contract the GP has with the RACF and suggests GPs new to RACFs should get one signed as it reminds both parties of their obligations. â€œThe Triage form is useful and I plan to request staff complete it before phoning me.â€? â€œThe CMA template is not the best I have seen. I use a form which gives the patient problem list, the medications, allergies, contact information and advanced care directive on the front page.â€? A CMA is a Comprehensive Medical Assessment, one of the new items renumerating GPs who work in nursing homes, and it contains information from patients, carers, family and previous doctors â€“ the sort of helpful information that conscientious GPs extracted before but were never paid to do.
â€œI see the CMA as an important communication tool. It should give a postage stamp picture of the patient to any other health professional using the patientâ€™s notes. I find it useful when I see other GPsâ€™ patients. I also use it in referrals to specialists.â€?
â€œMy only other comment is that we need to get more training in aged care for GPs. It is not just an extension of general practice,â€? she said.
Food is Medicine
ED. Best Practice Guide for Collaborative Care between GPs and RACFs, can be downloaded from www.racgp.org.au/agedcare. O
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Continued from P27
Telehealth: Good Medicine, Tricky Politics lever off too,â€? Michael said. â€œThey have come to an agreement with Ersis, one of the satellite internet companies, and we hope to put in additional bandwidth to share with multiple parties. Itâ€™s a very costefficient way of delivering telehealth into the sites that donâ€™t currently have adequate bandwidth.â€?
and I donâ€™t have the money to pay out tax. So Iâ€™ve stopped expanding.â€? â€œWe have jumped so many hurdles to get where we have. Iâ€™ve developed our own telehealth trolley, which has passed inspection and is now graded as a medical device. But thereâ€™s a question whether we can get over this last hurdle, which is the development of a sustainable financial model that allows our costs to be covered.â€?
Michael may not have seen any money from his venture but he has seen good medicine.
Looking to the future There is the possibility of funding from a pilot program for remote ear health and the State Government is not blind to the benefits of telehealth but it will take a commitment from government to support start-ups to allow them to survive this initial phase.
Q Ear health workers can consult specialists from remote locations.
There is support from other quarters â€“ Microsoft provides free software licences routinely to charities through DonorTec and there are health promotion projects in the wings coming off the back of proposed clinical telehealth models.
â€“ and desire â€“ for telehealth is the â€˜Rosieâ€™ initiative from the Kimberley Aboriginal Medical Council and the Kimberley-Pilbara Medicare Local, which have explored sharing satellite bandwidth for remote communities.
Perhaps the biggest indication of the need
â€œThatâ€™s a clever model which we hope to
â€œThereâ€™s not much money to be made from it, but my motivation is that itâ€™s great medicine. Both the ear health project and the RACFs are successful and I feel I canâ€™t stop because itâ€™s working. It is some of the most rewarding clinical medicine Iâ€™ve done in my career because the beneficiaries are the patients â€“ and they are the most disadvantaged patients we have in Australia.â€? â€œThe other beneficiaries are the State and Federal governments â€“ primary health is improved and tertiary health costs are saved.â€?O
By Ms Jan Hallam
Refer your patients to BreastScreen WAâ€™s Rose Clinic at David Jones Author competing interests: No relevant disclosures
BreastScreen WA in partnership with David Jones, has been operating a breast cancer screening clinic in the city store since the beginning of 2013. In addition to raising awareness of breast cancer VFUHHQLQJ DQG WKH SURÂżOH RI %UHDVW6FUHHQ :$ LW allows women who work and shop in the CBD the opportunity to have their screening mammograms. Women aged 40 and over with no breast symptoms are eligible for a free breast screening mammogram.
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March 1 2014 - PBS Listed for prevention of chronic migraine
Blepharospasm Chronic Migraine Cervical Dystonia
Severe primary prima axillary axillary hyperhidrosis hyperhidrosis Upper Limb Spasticityy Overactive B ladder Bladder Neurogenic Detrusor Overactivity
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BOTOX® has recently been listed on the PBS for prevention of Chronic Migraine in adult patients whom experience > 15 headache days per month with at least 8 of these being migraine.1 In a clinical study, 70% of BOTOX® treated patients had a 50% reduction of headache days (from baseline).2 Visit: chronicmigrainehelp.com.au for information about chronic migraine DQGWRêQGD6HFWLRQ1HXURORJLVWQHDU\RX
December 1 2012 - PBS Listed for treatment of severe primary axillary hyperhidrosis Section 100 restrictions: Patients 12 years or older with severe primary axillary hyperhidrosis who have failed or are intolerant to topical aluminum chloride hexahydrate after 1-2 months of treatment.1
% or greater reduction BOTOX BO OTO TOX X® provided at least 83% of patients with a 50% in sweating by week 4.2 Visit: Hy Hyperhidrosishelp.com.au H perh pe rh hid dro ossiish s el e p.com.au for information about abo out severe SULPDU\D[LOODU\K\SHUKLGURVLVDQGWRêQGD6HFWLRQ SULPDU\D[LOODU\K\SHUKLGURVLVDQGWRêQGD6HFWLRQ 'HUPDWRORJLVWRU1HXURORJLVWQHDU\RX
BEFORE PRESCRIBING, PLEASE REVIEW APPROVED PRODUCT INFORMATION AVAILABLE UPON REQUEST FROM ALLERGAN PTY LTD. PBS Information: Section 100 Restriction. Refer to PBS for full information. References: 1. Medicare Australia. www.medicareaustralia.gov.au/provider/pbs/drugs1/botulinum.jsp, 2. BOTOX® Approved Product Information. Australian Minimum Product Information: BOTOX® (botulinum toxin type A) puriﬁed neurotoxin complex is a prescription medicine containing 100 units (U) or *200 units (U) of botulinum toxin type A for injection. Indications: *Overactive bladder with symptoms of urinary incontinence, urgency and frequency, in adult patients who have an inadequate response to or are intolerant of an anticholinergic medication *urinary incontinence due to neurogenic detrusor overactivity resulting from a deﬁned neurological illness (such as spinal cord injury or multiple sclerosis) and not controlled adequately by anticholinergic agents; prophylaxis of headaches in adults with chronic migraine (headaches on at least 15 days per month of which at least 8 days are with migraine); strabismus; blepharospasm associated with dystonia, including benign blepharospasm & VIIth nerve disorders (hemifacial spasm) in patients 12 years & over; cervical dystonia (spasmodic torticollis); focal spasticity of the upper & lower limbs, including dynamic equinus foot deformity due to spasticity in juvenile cerebral palsy patients 2 years & older; severe primary hyperhidrosis of the axillae; focal spasticity in adults; spasmodic dysphonia; upper facial rhytides (glabellar lines, crow’s feet and forehead lines) in adults. Contraindications: *Intradetrusor injection - acute urinary tract infection, acute urinary retention in patients who are not routinely catheterising, or who are not willing and/or able to initiate catheterisation post-treatment, if required; hypersensitivity to ingredients; myasthenia gravis or Eaton Lambert Syndrome; infection at injection site(s). Precautions: Different botulinum preparations are not therapeutically equivalent. Exercise extreme caution should substitution with another botulinum preparation be necessary. Botulinum toxin effects may be observed beyond site of local injection with symptoms consistent with mechanism of action and reported hours to weeks after injection. Symptoms may include muscular weakness, ptosis, diplopia, blurred vision, facial weakness, swallowing and speech disorders, constipation, aspiration pneumonia, difﬁculty breathing and respiratory depression. Risk of symptoms is greatest in children with spasticity, but can also occur in adults particularly those on high doses. Swallowing/ breathing difﬁculties can be life threatening and there have been reports of death (relationship to BOTOX® not established). Serious adverse events including fatal outcomes have been reported in patients who had received BOTOX® injected directly into salivary glands, the oro-lingualpharyngeal region, oesophagus and stomach. Hypersensitivity reactions such as anaphylaxis and serum sickness, as well as urticaria, soft tissue oedema and dyspnoea; inﬂammation at injection sites; excessive weakness in target muscle; pregnancy & lactation. Generalised weakness & myalgia may be related to systemic absorption. Blepharospasm: Reduced blinking following injection of the orbicularis muscle can lead to corneal pathology. Caution with patients at risk of angle closure glaucoma, including anatomically narrow angles. Strabismus: Inducing paralysis in extraocular muscles may produce spatial disorientation, double vision or past pointing. Use in chronic paralytic strabismus only in conjunction with surgical repair to reduce antagonist contracture. Spasticity: Not likely to be effective at a joint affected by a known ﬁxed contracture. Cervical Dystonia (spasmodic torticollis): Possibility of dysphagia or dyspnoea. May be decreased by limiting dose injected into the sternocleidomastoid muscle to <100U. Primary Hyperhidrosis of the Axillae: Consider causes of secondary hyperhidrosis to avoid symptomatic treatment. Spasmodic Dysphonia: Laryngoscopy in diagnostic evaluation is mandatory. Avoid treatment in patients due to have elective surgery requiring general anaesthesia. Chronic migraine: Due to difﬁculties in establishing a diagnosis of chronic migraine, patients being considered for prophylaxis of headaches with BOTOX® should be evaluated by a neurologist or pain management specialist prior to receiving treatment with BOTOX®. *Bladder Dysfunction: The intradetrusor administration of BOTOX® is only to be conducted by a urologist/urogynaecologist trained in this technique or by a urologist/urogynaecologist under the direct supervision of a urologist/urogynaecologist who has been so trained. *Caution when performing cystoscopy. *Assess post-void residual volume post-treatment. *Overactive Bladder: Patients treated may show increased likelihood of developing urinary retention and/or urinary infection. Men with overactive bladder and signs or symptoms of urinary obstruction should not be treated with BOTOX®. *Neurogenic Detrusor Overactivity: autonomic dysreﬂexia associated with the procedure could occur, which may require prompt medical therapy. Paediatric Use: Safety & effectiveness below 18 years have not been established for urinary incontinence due to *overactive bladder or neurogenic detrusor overactivity, chronic migraine and below 12 years not established for blepharospasm, hemifacial spasm, cervical dystonia, hyperhidrosis, spasmodic dysphonia or upper facial rhytides. Safety & effectiveness below 2 years not established for focal spasticity. Caution should be exercised when treating patients with signiﬁcant disability & co-morbidities and elderly. Caution should be exercised after treatment of BOTOX® as it can have an effect on the ability to drive and use machines. Interactions: The effect of botulinum toxin may be potentiated by aminoglycoside antibiotics or any other medicines that interfere with neuromuscular transmission. Caution should be exercised when BOTOX® is used in patients taking any of these medicines. Excessive weakness may be exacerbated by administration of another botulinum toxin prior to the resolution of the effects of a previously administered botulinum toxin. Adverse Reactions: Usually transient & occur within ﬁrst week of injection. *1% Localised pain, tenderness, bruising, infection, local & general weakness, erythema, oedema, ptosis, irritation/tearing, vertical deviation, diplopia, sub-conjunctival & conjunctival haemorrhages, reversible increase in intra-ocular pressure, trigger ﬁnger, clumsiness, falling, hypokinesia, increased frequency of micturition, joint dislocation, muscle spasms, convulsions, nasopharyngitis, dyspnoea, pneumonia, dry mouth, vomiting, contusion, leg pain/cramps, fever, knee pain, ankle pain, lethargy, arm pain, hypertonia, fever/ﬂu syndrome, accidental injury, incoordination, paraesthesia, asthenia, headache, hyperkinesia, neck pain, dysphagia, perceived increase in non-axillary sweating, vasodilation, paralytic dysphonia (breathy dysphonia), aspiration, stridor, technical failure, blepharoptosis, face pain, ecchymosis, skin tightness, nausea, temporary lateral lower eyelid droop, eyebrow ptosis, eyelid swelling, aching/itching forehead, feeling of tension, seizures, migraine, facial paresis, musculoskeletal stiffness, myalgia, musculoskeletal pain, muscle tightness, injection site pain, pruritus, rash, *urinary tract infection, *urinary retention, fatigue, insomnia, constipation, muscular weakness, gait disturbance, bladder diverticulum, haematuria, *dysuria, autonomic dysreﬂexia, *bacteriuria, *residual urine volume, *pollakiuria. Dose/Administration: Use one vial for one patient. Store reconstituted BOTOX® in refrigerator; use within 24 hours of reconstitution. *Overactive Bladder: 100U injected in the detrusor muscle. Neurogenic Detrusor Overactivity: 200 U injected in detrusor muscle. Chronic migraine: 155U to 195U administered intramuscularly (IM) divided across 7 speciﬁc head/neck muscle areas. Blepharospasm: Initially 1.25U to 2.5U injected into upper lid medial & lateral pre-tarsal orbicularis oculi & into lower lid lateral pre-tarsal orbicularis oculi. Cumulative dose over 2 months should not exceed 200U. Strabismus: Initial doses 1.25 – 2.5U to 2.5 – 5.0U per muscle. Maximum single injection for any one muscle is 25U. VIIth Nerve Disorders (hemifacial spasm): Dosing as for unilateral blepharospasm. Inject other facial muscles as needed. Focal Spasticity in Children 2 Years & Older: 0.5-2.0U/kg body weight for upper limb & 2.0-4.0U/kg body weight for lower limb. 4U/kg or 200U (the lesser amount) for equinus foot deformity. Other muscles range 3.0-8.0U/kg body weight & do not exceed 300U divided among muscles at any treatment session. Focal Spasticity in Adults: Individualise dosing. Cervical Dystonia (spasmodic torticollis): Individualise dosing. Maximum dose 360U every 2 months. Primary Hyperhidrosis of the Axillae: 50U intradermally to each axilla in 10-15 sites 1-2 cm apart. Spasmodic Dysphonia: Bilateral injections. Individualise dosing. Glabellar Lines: 2x4U in each corrugator muscle & 4U in the procerus muscle for 20U total dose. Crow’s Feet: 2-6U/injection site, 3 sites bilaterally in lateral orbicularis oculi. Forehead Lines: 2-6U/injection site, 4 sites in frontalis muscle. Date of TGA approval: 06 August 2013
*Please note change(s) in Product Information
Allergan Australia Pty Ltd 810 Paciﬁc Highway, Gordon NSW 2072 ABN 85 000 612 831 BOTOX® and Our Pursuit. Life’s potential.® are registered trademarks of Allergan. © Allergan Inc, 2014 AU/0203/2014 Date of preparation: May, 2014 30
?Transfusion – Patient Blood Management We take more notice of good clinical practice when it also claims to save money – and so it is with avoiding blood transfusions. Was it WWII or the Red Cross? Older doctors welcomed blood transfusion: packed cells for the elderly or blood bank visits when things got tricky in theatre. Transfusions fixed it. Then came HIV, JKD, HCV and suspicion of undetected bloodborne prions. And now we are reappraising the clinical value and costs of what we do, given the shrinking donor pool and demands of an ageing population. The WA Health Department and the National Blood Authority are hosting their inaugural conference in Perth, June 20-21, to help us understand the issues. Patient Blood Management as a Standard of Care in Australia says it all – patient care comes first. When each blood transfusion costs an estimated $900, there is also a $65m yearly cost consideration for WA (74,000 RBC units used in 2009-10). Keynote conference speakers will cover exotic blood use (Michael Lill, USA), cardiac failure and iron deficiency (Stephan Von Haehling, Germany), and the true cost of blood (Axel Hofmann, Austria). Mr Hoffman recently attracted the attention of WA’s The Sunday Times, which said he was an economist and health scientist with Jehovah’s
Witness as his religion, whose company had derived income from both the Health Department and some pharmaceutical companies, presumably because of his expertise in this area. See www.health.wa.gov. au/bloodmanagement/home for full program details.
What is PBM? Patient Blood Management aims to improve patient outcomes by avoiding unnecessary blood transfusions. Fremantle Hospital, a national leader in this, won an award from State Health for its efforts. The concepts of iron balance and transfusion impact on waitlists for elective surgery, something dear to the hearts of both doctors and politicians. The three principles of PBM are: (i) enhance erythropoiesis, (ii) reduce blood loss and (iii) ensure patient tolerance of anaemia is properly accommodated. While more restrictive transfusion thresholds are now part of the equation, other things are important for both surgical and medical disorders. Patients aged over 70 use about half the donated blood products. On the other hand, about 70% each of RBC units, platelets and fresh frozen plasma are used by hospital
doctors working in haematology, oncology, gastroenterology, general surgery, ED and cardiothoracic surgery (2001-2 figures). These people need a deeper understanding of PBM. In the elderly, consumption of blood and blood products are said to be rising because more malignancies are treated with bone marrow suppressive chemotherapy, and there is more transfusion-dependent myelodysplasia. In patients receiving myeloablative chemotherapy, experts say haemoglobin and platelet ‘triggers’ for transfusions can be lowered without compromising patient care, and other measures used. The experts also found that lower transfusion ‘triggers’ for most critical care patients (reduced from Hb <100 g/L to <70 g/L) did not worsen clinical outcomes – in fact, it is more liberal transfusion for anaemia that appears to worsen things.
A role for community doctors The GP can prevent postponement of a patient’s surgery due to low iron stores. That is particularly relevant in cardiothoracic and orthopaedic surgery where overseas experience has shown that minimising perioperative transfusions significantly Continued on P35
Viewpoint: Hospital Haematologist It’s the doctor’s task to investigate scenarios when body iron stores are depleted, and manage the underlying problem and perhaps replenish iron accordingly, including IV iron. Functional iron deficiency requires different thinking.
Dr Leahy said blood transfusion should not be used for the default management of anaemia. The previous transfusion guidelines from 2001 have been developed into Patient Blood Management Guidelines, now part of Australian public hospital practice. “Preoperative optimisation of haemoglobin and iron status will provide a buffer in cases of blood loss at operation, thereby hopefully obviating the need for blood transfusion,” he said. Doctors everywhere should think of iron deficiency as a systemic disorder affecting all tissues of the body, hence the fatigue. How we interpret laboratory results varies with the circumstances.
Q Dr Michael Leahy, Head of the Haematology Department, Fremantle Hospital
“Even with a normal Hb one can be iron deficient, as evidenced by low ferritin levels commonly seen in women with menorrhagia who respond well to oral, or if intolerant, IV iron. Diagnosis depends on a ferritin below
the reference range of the laboratory, such as less than 15 ug/l but may be considered if ferritin is less than 30 ug/l, especially if the transferrin saturation is less than 20%.”
“This is associated with adequate body iron stores but inability to use them because of underlying chronic disease. The ferritin may be greater than 100ugm/L and the transferrin saturation less than 20%. Elevated levels of hepcidin in chronic disease leads to reduced iron absorption from the gut and increased sequestration of iron in the bone marrow and reticuloendothelial macrophages. This block in iron uptake by the red cell precursors may be overcome by giving IV iron alone or in combination with therapeutic erythropoietin.” O Reference: Leahy M.F., Mukhtar S.A. From blood transfusion to patient blood management. Intern Med J. 2012 Mar;42(3):332-8.
Obesity: Quo vadis? Working with obese patients, Dr Len Henson’s approach includes a realisation that “Every night and every morn, Some to obesity are born. (apology to author)”
o manage obesity successfully requires more than the “eat less and exercise more” doctrine that remains the core advice given to the unfortunate portly who seek help from health practitioners. Should we expect a different outcome from obesity advice that clearly failed previously? It seems “common sense ain’t that common” in obesity management when the weight loss industry is worth around $6.6 billion this year, in Australia, and Australians are not getting thinner.
Successful weight loss is a particularly difficult feat. It does not boil down to a lack of discipline, motivation or weakness on the part of the unfortunate obese person. There are a number of important considerations. The Human Genome Project led to the identification of several human obesity genes. There is a common hereditary link in patients that present at our bariatric clinic – they mostly come from obese families. One
young male evaluated for bariatric surgery at age 18 needed to lose 11kg to attain the 180kg allowable operating table weight. Both his mother and father had had bariatric procedures. A year later, he had ballooned to 233kg, in spite of support. Why does that happen? The morbidly obese person functions differently. More so, certain foods seem to induce epigenetic changes that drive obesity. In the morbidly obese, Le Roux et al. confirmed that the secretion of humoral factors ghrelin, peptide tyrosine tyrosine (PYY) and glucagon-like peptide-1 (GLP-1) does not follow a normal pattern and does not signal hunger or satiety to the brain. Satiety mechanisms are also overridden by higher centres in the brain and the obese patient has a constant yearning to eat. As you can imagine, this is a powerful behavioural driver and the obese person often falls into a vicious cycle of overindulgence in tastier energy dense food, followed by more weight
gain, guilt, depression, hopelessness, comfort eating, weight gain, guilt, and so forth. Kaplan and Sadock teach that less than 10% of patients will effectively institute a radical lifestyle change. We see the same failure rates in diet and exercise regimes. Very few of the morbidly obese, and the overweight in general, are able to keep lost weight off. In contrast, laparoscopic Roux-en-Y gastric bypass surgery and gastric sleeve surgery, restored normal gut hormone secretions, aiding weight loss. It is especially the humoral changes and altered taste sensation that aids weight loss, more so than the associated mal-absorption. The restoration of normal gut-hormone secretion induces behavioural changes (confirmed by functional MRI brain scanning) and maintains weight loss. After laparoscopic gastric banding but some form of vagus nerve signalling seems to enable prolonged satiety, with no humoral changes. The problem of rising obesity rates is clearly Continued next page
Patient Blood Management as a Standard of Care in Australia: Past, Present and Future The Western Australia Department of Health and the National Blood Authority are proud to host Australia’s inaugural Patient Blood Management Conference “ Patient Blood Management as a Standard
of Care in Australia: Past, Present and Future”. The Conference will be held in Perth on 20 and 21 June 2014 at the Perth Convention and Exhibition Centre. Speakers at the Conference will include: x Michael Lill (United States) who will share his experience of restrictive blood use with myelodysplastic syndrome and bone marrow transplant patients. x Stephan Von Haehling (Germany) who will talk about iron deficiency in cardiac failure and management of anaemic medical patients. x Axel Hofmann (Austria), a health economist who will present the facts about the true cost of blood. Registrations for the Conference are filling fast. To see the full program and nd to reserve your yo place for this exciting event, please visit www.health.wa.gov.au/bloodmanagement/home nt/home For more information please contact Trudi.Gallagher@health.wa.gov.au u
Gluten intolerance: an overview G
luten intolerance is classically associated with immune-mediated coeliac disease (CD) but non-coeliac wheat intolerance has also been documented. There has been a four-fold increase in CD in the last 50 years and gluten-free products are booming in supermarkets. Coeliac Australia says 0.3% of the population have been diagnosed with CD, yet 28% restrict gluten intake for perceived health benefits.
Coeliac disease CD is a T cell mediated immune reaction to gliadin in gluten, mainly from wheat, rye, barley and oats. Almost all dietary gluten is produced during food processing by combining gliadin and glutenin proteins, with gluten rare in nature. The immune reaction damages small bowel villi, reducing absorptive surface area leading to malabsorption. Subsequent nutritional deficiencies, gastrointestinal disturbance and anaemia may develop. Additional complications can include osteomalacia, osteoporosis, infertility, mouth ulcers, miscarriage and an increased risk of GI tract adenocarcinoma and lymphoma. Diagnosis is by serology (IgA antibodies to tissue transglutaminase and deaminated gliadin peptide), and small bowel biopsy
demonstrating villous atrophy. Before biopsy, patients must consume significant amounts of gluten (4 slices of wheat bread or equivalent) for 6 weeks to avoid a false negative result. Genetic testing may help if the diagnosis is unclear or gluten has been avoided: 99.6% of CD patients exhibit HLA DQ2 and DQ8, so their absence effectively rules out CD. However, a positive gene test only indicates susceptibility to CD, since only one in 30 develop CD. A positive test should be followed by gluten challenge and biopsy.
/PODPFMJBDHMVUFOTFOTJUJWJUZ NCGS is a gluten intolerance in the absence of CD or wheat allergy. Irritable bowel syndrome-type symptoms are typical, with a beneficial response to wheat avoidance. However, recent research suggests NCGS may represent intolerance to wheat and other food sources of FODMAPs (fermentable, poorly absorbed short chain carbohydrates), rather than a reaction to gluten per se.
(MVUFOBWPJEBODF Life-long total gluten avoidance is required in CD, which can be challenging. Many gluten-free substitutes for bread, pasta, cereals and flour are less palatable, lower in fibre, vitamins, minerals and protein. They are mostly of higher GI and cost more.
#Z+P#FFS 4FOJPS%JFUJUJBOBOE Diabetes Educator. 5FM Patients report annual additional food bills of $500-$1000. Adherence to a gluten-free diet requires education and motivation, which can be assisted by a specialist dietitian. Gluten unexpectedly appears in foods such as ice cream, soy sauce, ketchup and cheese spreads. In contrast, some wheat by-products have been highly processed and contain no gluten e.g. dextrose, glucose syrup and caramel colouring. Often people believe oats are gluten free, but commercial oats are frequently contaminated with wheat or barley so are not suitable. Some â€˜wheat freeâ€™ oats said to be uncontaminated may also exacerbate CD. Some medications and supplements in Australia contain gluten in excipients (e.g. some aspirin, doxycyclin, paracetamol/ codeine combinations, vitamin and mineral supplements). Some cosmetics also contain gluten, e.g. lipsticks, but rarely induce a flare-up of CD. Patients diagnosed with CD should be encouraged to seek support from Coeliac Australia (www.coeliac.org.au) and a specialist dietitian. O Declaration: No author competing interests.
Continued from previous page
Obesity: Quo vadis? multifactorial. In the UK Twins Study, highlighted in a Horizon television program â€œThe Truth About Fatâ€?, identical twins had markedly similar environments, lifestyles and diet, but an obvious weight differential. This study led to the discovery of genetically miniscule differences in amylase gene expression and associated enzyme levels. This is one of many studies describing the epigenetic nature of obesity, where some, or many, of the 50 or so identified obesogenic gene loci can be switched on or off. We find ourselves in an obesogenic environment. Popular television programs advocate fine cuisine and the art of food, stimulating appetites all over Australia. Every
suburb has a cafĂŠ strip with fast food outlets and restaurants. Tasty food is available in abundance so that feeding is not a survival strategy but a major social activity where regular overconsumption of energy dense food is commonplace. And we havenâ€™t touched on the subject of alcohol and energy drink consumption, nor sugar-bomb soft drinks! The question is what to do about it? At present the most economic option for long term treatment, for the morbidly obese
at least, seems to be an operation. It is undoubtedly the best method of therapy for obesity induced Type II Diabetes. O
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any infections can be caught overseas; mosquito-borne illnesses such as dengue, chikungunya and malaria amongst them. Most of these cannot be passed on to others on return to WA as the mosquito vectors are not here. However, respiratory infections and measles can certainly spread directly to others back in Perth.
recommended to all travellers who do not have contraindications.
Measles and influenza
Insidious microbes that become part of our â€˜normal floraâ€™ may not be â€˜traditionallyâ€™ seen as travel-related. This applies to multi-resistant gram negative (MRGN) bacteria. More commonly found in Asia and parts of Europe and North America, they may colonise the gastrointestinal tract of travellers. Those hospitalised while overseas are at greatest risk.
Recently there have been measles outbreaks in the Philippines, Vietnam and Indonesia, including Bali. A number of secondary cases have been diagnosed in household members and the general public in Australia (from ongoing transmission) originating from returned travellers. Measles is probably the most transmissible of all infections; via respiratory aerosols that may still be contagious, even when the person with active measles infection has left the room. Many of those who contracted measles did not realise that they had been only partially vaccinated and were susceptible (whereas almost everyone born before 1966 would have been exposed to measles, and should be immune). Influenza is the most common vaccinepreventable illness in travellers. The current seasonâ€™s Australian influenza vaccine is
The â€˜common garden varietyâ€™ vaccines should not be forgotten when thinking of prophylaxis. All travellers should be up-todate with all their routine vaccinations in addition to the more exotic destinationspecific recommendations.
Most people would not develop symptoms. However, those having a medical procedure after returning home, for example a prostate biopsy, would be at higher risk of having clinical infection with an MRGN. Doctors need to ask about recent travel before any invasive procedures, as the antibiotic prophylaxis may need to be changed. Similarly a person who develops a UTI and has recently travelled overseas is at higher risk of being infected with an MRGN. O Author competing interests: None relevant
,&:$-*/*$"-10*/54 Pre-travel t &OTVSFASPVUJOFWBDDJOBUJPOTBSF up-to-date. t $POTJEFSJOGMVFO[BWBDDJOBUJPOT GPSFWFSZPOFBTJOGMVFO[BDJSDVMBUFT throughout the year in tropical areas. Post-travel t 5IJOLNFBTMFTJGGFWFS SFECMPUDIZ SBTI DPOKVODUJWJUJTBOEDPSZ[BM symptoms. t .FBTMFTJTWFSZDPOUBHJPVTBOE patients need to notify the practice before coming in (and practice staff trained to respond). t 3FUVSOFEUSBWFMMFSTXJUI.3(/ colonisation may place themselves at increased risk. Testing t .FBTMFT4FSPMPHZBOE1$3 UISPBU swab and urine). t *OGMVFO[BBOEPUIFSSFTQJSBUPSZWJSVTFT 1$3 UISPBUBOEOBTPQIBSZOHFBM swabs or nasopharyngeal aspirate). t 6TVBMDVMUVSFBOETFOTJUJWJUZGPS DMJOJDBMJOGFDUJPOTEFUFDUT.3(/ and asymptomatic screening is only recommended for admission to healthcare facilities.
Continued from P31
?Transfusion â€“ Patient Blood Management reduces hospital stay and cost, along with improving patient outcomes. IV iron may do the job in a quarter of the time of oral supplements (and very risky injections are a distant memory). Iron status thinking has changed; â€˜Normal ironâ€™ now begs the question, â€˜Normal for what?â€™ While one review article suggests healthy people can tolerate a Hb as low as 50 g/L with only minor haemodynamic and myocardial effects, problems arise if surgery is needed. Hence, State Health hospital protocols are now in place for assessing someoneâ€™s fitness for elective surgery, when it comes to iron status. With enough â€˜iron in the tankâ€™, it is claimed people withstand trauma or illness better, and resist infection. This is all good news in an age of chronic illness and attempts to reduce hospital bed stays. Times have changed. Blood transfusions are not the panacea first imagined. PBM asks you to think of transfusions as tissue transplants.O
By Dr Rob McEvoy
Initiating insulin for Type 2 Diabetes T
here are three main types of insulin regimens for people with Type 2 Diabetes - Basal, Biphasic and Basal Bolus Insulin. Before considering insulin therapy it is important to choose a patient-specific Hba1c target.
Which patient and when? A target Hba1c of 7% is still reasonable for most patients. Tighter glycaemic control is ideal in younger patients with a shorter duration of diabetes and without significant co-morbidities. A higher Hba1c target (around 8%) is reasonable in those with significant co-morbidities (in particular cardiovascular) or those experiencing problematic hypoglycaemia. In those with limited life expectancy, the primary objective is to avoid symptomatic hyperglycaemia. Other factors that need to be considered include capacity to inject insulin and selfmonitor, dietary habits and physical activity.
What insulin(s) to use? I find at least two weeksâ€™ of intensive glucose testing with â€˜pairedâ€™ readings (pre-meal and two hours post-meal) instructive when determining the most appropriate insulin therapy. Once familiar with time profiles of the different insulins, you just need to match the insulin regimen to the patientâ€™s pattern of hyperglycaemia.
(1) Basal insulin â€“ long- or intermediateacting. Most suitable if the patient has morning hyperglycaemia and minimal postprandial hyperglycaemia. (2) Biphasic insulin â€“ a mixture of shortand intermediate-acting insulin. Can be used once daily, twice and, occasionally, three times a day. It is suitable for those with a combination of morning hyperglycaemia plus post-prandial rise. Patients require routine mealtimes. (3) Basal bolus insulin (basal insulin + mealtime rapid insulin). Most suitable for those requiring tight glycaemic control, those with erratic glucose readings or diet, and those not sufficiently controlled on other insulin regimens. Insulin delivery devices may influence choice of insulin. Some devices are more suitable in elderly patients with poor dexterity, visual impairment or tremor (seek the advice of a Diabetes Educator for what is current).
What starting dose? Generally speaking, a â€˜start low, go slowâ€™ approach is safest. Basal Insulin â€“ 0.2U/kg or 8-12 units Biphasic Insulin â€“ 0.15U/kg or 8-10 units. Basal Bolus Insulin â€“ Basal as above, Bolus 0.1U/kg or 6 units
#Z%S#SFUU4JMMBST Endocrinologist 4+0(.VSEPDI
The starting dose is not critical, however adequate titration is.
How to titrate insulin? Inadequate titration is often behind failure to achieve targets as well as intensification of insulin (e.g. changing basal to biphasic when fasting glucose target is reached but significant post prandial hyperglycaemia remains). Various methods are appropriate. Basal Insulin â€“ 1U/day until fasting is 6, 2U every three days or use of titration tool (provided by manufacturer). Studies would suggest that a dose of about 0.6U/kg is required to achieve an Hba1c of 7%, as a guide to final dose. Biphasic Insulin â€“ Titration tools exist, however, using the experience of a Diabetes Educator to oversee is usually best. Basal Bolus Insulin â€“ Titrate basal as above and then bolus according to two hours postmeal readings. O Further reading http://clinical.diabetesjournals.org/content/23/2/78.full
The author has provided accredited RACGP insulin education courses funded by insulin manufacturers.
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Preventing diabetes damage to the eye
By A/Prof Angus Turner, 0QIUIBMNPMPHJTU
urrent challenges are the burden of retinal screening required and dealing with the pathology identified, particularly in the face of intensive treatments and investigations, including the regular use of intravitreal injections. These hurdles are amplified in the remote areas but improved technology and future telehealth provides scope for meeting that demand.
Fenofibrates (Lipidil) Recent data from two large multi-centre randomised controlled trials (5,6) show that the daily use of fenofibrates in type 2 diabetic patients was safe and reduced the progression of diabetic retinopathy, as well as the need for laser treatment, in patients with established retinopathy. In both studies, prescription of fenofibrate was in addition to a statin.
Anti-VEGFs Regular (often 4-6 weekly) injections of anti-VEGFs are effective at improving visual acuity where thickening of the retina involves the fovea. Laser treatment is effective for maculopathy not involving the fovea. O
Retinal screening for retinopathy remains the mainstay of prevention for blinding complications of diabetes. Optometrists or ophthalmologists should see non-Indigenous people with diabetes every two years. For Indigenous people with diabetes, annual retinal examination is recommended (1). In many rural areas, retinal screening is available on digital cameras to allow for opportunistic screening (2). In 2013, vision testing and eye examination (including the need to ensure retinal screening for people with diabetes) was introduced as a mandatory component of the adult health check for Indigenous populations (MBS Item 715) (3).
Management of diabetic maculopathy For up to 35 years destructive laser photocoagulation of the retina has been the mainstay of treatment. However, therapeutic options are evolving with the introduction of new imaging modalities, in particular optical coherence tomography (OCT) and treatments such as anti-vascular endothelial growth factor (VEGF) therapies (4).
QAngus Turner performing laser in a remote clinic â€“ equitable access to investigations and treatment for diabetic eye disease needs continued advocacy. Patient permission granted.
QACT showing diabetic maculopathy with retinal thickening involving the fovea. References: 1. NHMRC. Guidelines for the Management of Diabetic Retinopathy. Canberra: NHMRC, 2008. 2. Retinal screening locations: www.outbackvision.com.au 3. http://www9.health.gov.au/mbs/fullDisplay. cfm?type=note&qt=NoteID&q=A35 4. Update on the management of diabetic retinopathy. Focal Points, AAO. Vol XXIX number 5, June 2011. 5. Keech AC, Mitchell P, Summanen PA, et al. Effect of fenofibrate on the need for laser treatment for diabetic retinopathy (FIELD study): a randomised controlled trial. Lancet 2007; 370: 1687â€“1697.
6. ACCORD Study Group and ACCORD Eye Study Group. Effects of medical therapies on retinopathy progression in type 2 diabetes. New Engl J Med 2010; 363: 233â€“244
Competing interests statement: no relevant disclosures.
Supporting Ophthalmic Research, Education and Overseas Projects
EYE SURGERY FOUNDATION Our Vision Is Improved Vision After 18 months of expansion, the Eye Surgery Foundation amalgamated two buildings and re-commenced surgical procedures in November. The new day hospital is twice the size â€“ four operating Dr Ross Agnello Tel: 9448 9955 Dr Malcolm Burvill Tel: 9275 2522 Dr Ian Chan Tel: 9388 1828 %S4UFWF$PMMFZ Tel: 9385 6665 Dr Dru Daniels Tel: 9381 3409 %S#MBTDP%4PV[B Tel: 9258 5999
%S(SBIBN'VSOFTT Tel: 9440 4033 %S,BJ(PI Tel: 9366 1744 %S%BWJE(SFFS Tel: 9481 1916 Dr Boon Ham Tel: 9474 1411 Dr Philip House Tel: 9316 2156
theatres, a dedicated Laser room with a Femtosecond Laser, two recovery rooms, large reception, and a spacious staff room. The hospital is managed by Perth Eye Centre P/L. %S#SBE+PIOTPO Tel: 9301 0060 %S+BOF,IBO Tel: 9385 6665 Dr Ross Littlewood Tel: 9374 0620 %S/JHFM.PSMFU Tel: 9385 6665 Dr Robert Patrick Tel: 9300 9600
Dr Rob Paul Tel: 9330 8463 %S+P3JDIBSETTel: 9321 5996 %S4UVBSU3PTT Tel: 9250 7702 Dr Angus Turner Tel: 9381 0802 Dr Michael Wertheim Tel: 9312 6033
Functional (non-ulcer) dyspepsia D
gastroparesis, colonoscopy for inflammatory bowel disease).
yspepsia is common, affecting about 25% of the population each year (if Rome III diagnostic criteria are applied â€“ see below). Of these people, up to 75% have functional (â€˜idiopathicâ€™ or â€˜nonulcerâ€™) dyspepsia with no underlying cause identified and symptoms both persistent for the last three months or more, and onset at least six months before diagnostic evaluation. Although functional dyspepsia does not affect survival, it impacts on quality of life and can be a burden on the health system.
'VODUJPOBMEZTQFQTJB If all investigations are negative, and the empirical trial of PPI for up to eight weeks has not helped, the treating doctor may then look for psychological problems underlying non-ulcer or functional dyspepsia. A low-dose tricyclic anti-depressant (TCA) (e.g. amitriptylyine 10mg nocte or nortriptyline 5mg nocte) may help, followed by prokinetics (e.g. domperidone). For those who fail to respond to the above treatments, psychological therapy may be useful e.g. anxiety or panic disorder.
0GUFOBEJBHOPTJTPGFYDMVTJPO About 25% of patients with dyspepsia have an underlying organic cause (e.g. peptic ulcer disease, GORD, gastro-oesophageal malignancy, biliary pain, drug-induced dyspepsia, chronic pancreatitis, coeliac disease, or inflammatory bowel disease).
Several dietary, complementary, and alternative medicine approaches to functional dyspepsia have been described. However, further studies are needed before these approaches can be routinely recommended.
History, physical examination, and laboratory evaluation allows the differential diagnosis to be narrowed. It helps identify issues such as NSAID-induced dyspepsia (as many as 20% of users) and importantly, any alarm features indicative of the need for early investigation. Alarm features include: t "HFPMEFSUIBOZFBSTXJUIOFXPOTFU dyspepsia t 'BNJMZIJTUPSZPGVQQFSHBTUSPJOUFTUJOBM cancer t 6OJOUFOEFEXFJHIUMPTT t (BTUSPJOUFTUJOBMCMFFEJOH t 1SPHSFTTJWFEZTQIBHJB t 0EZOPQIBHJB JFQBJOGVMTXBMMPXJOH
t 6OFYQMBJOFEJSPOEFÄ•DJFODZBOBFNJB t 1FSTJTUFOUWPNJUJOH t 1BMQBCMFNBTTPSMZNQIBEFOPQBUIZ t +BVOEJDF Appropriate blood tests help identify or exclude suspected problems, and gastroscopy assists in evaluating alarm features, particularly new onset dyspepsia in patients over age 55, where stomach biopsies can detect H. pylori, leading to eradication
Rome III Diagnostic Criteria One or more of the following: t 1PTUQSBOEJBMGVMMOFTT t &BSMZTBUJFUZ JOBCJMJUZUPÄ•OJTIB normal-sized meal) t &QJHBTUSJDQBJOPSCVSOJOH Currently the most widely accepted diagnostic criteria for dyspepsia. 38
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References: 1. Talley NJ, American Gastroenterological Association. American Gastroenterological Association medical position statement: evaluation of dyspepsia. Gastroenterology 2005; 129:1753-5. 2. Talley NJ, Vakil NB, Moayyedi P. American gastroenterological association technical review on the evaluation of dyspepsia. Gastroenterology 2005; 129: 1756-80. 3. Lacy BE, Talley NJ, Locke GR 3rd, et al. Review article: current treatment options and management of functional dyspepsia. Aliment Pharmacol Ther 2012; 36:3-15. 4. Tack J, Talley NJ, Camilleri M, et al. Functional gastroduodenal disorders. Gastroenterology 2006; 130:1446-79. 5. Overland MK. Dyspepsia. Med Clin North Am. 2014;
therapy in addition to treatment for any other problem. Patients 55 years or younger without alarm features are best tested for H. pylori (using a 13C-urea breath test or stool antigen test) and treated if positive. If symptoms remain, an empirical trial of acid suppression with a PPI for 4-8 weeks is indicated. Those patients who respond to H. pylori treatment or PPI therapy can be managed without further investigation. Those who do not respond have either: persistent H. pylori infection; an alternate diagnosis; or functional dyspepsia. Careful reassessment takes heed of the type of ongoing symptoms, effects of current treatment, and compliance with medications. Upper endoscopy allows H. pylori culture and sensitivity testing in patients who have not responded to previous treatment and duodenal biopsies to exclude coeliac disease.
98(3): 549-564. O
'6/$5*0/"-%:41&14*",&:10*/54 t $PNNPOBOEBGGFDUTRVBMJUZPGMJGF t *UJTBEJBHOPTJTPGFYDMVTJPO particularly of causes with alarm symptoms. t )QZMPSJFSBEJDBUJPOBOE11*BSF cornerstones of initial management. t %JGGJDVMUUPUSFBUBOESFRVJSFTDBSFGVM FYQMBOBUJPOBOEBUSVTUJOHSFMBUJPOTIJQ between the treating doctor and patient.
Declaration: No author competing interests.
Normal upper endoscopy may then lead to physical evaluation based on the type of ongoing symptoms (e.g. gallbladder ultrasound, gastric emptying study for medicalforum
Low testosterone and Type 2 diabetes in men M
The importance of RCTs to clarify the role of testosterone to preserve health in the growing population of older Australian men cannot be overstated. Only RCTs can translate observational data linking low testosterone levels to poorer health outcomes in ageing men to appropriate interventions .
en with Type 2 diabetes tend to have lower levels of testosterone compared to non-diabetic men . This is not unexpected, as Type 2 diabetes is associated with central obesity and insulin resistance, and central obesity inhibits pituitary secretion of luteinising hormone (LH) while insulin resistance reduces the testicular response to LH (for review, see ). Conversely, low testosterone levels predispose to loss of muscle mass, accumulation of fat, and worsening of insulin resistance. Thus weight gain can further reduce circulating testosterone concentrations, reinforce adverse changes in body composition and worsen glycemic control. Treatment of Type 2 diabetes involves lifestyle changes to promote healthy eating, regular physical activity and reduction of excess weight. This is accompanied by measures to directly reduce cardiovascular risk (blood pressure control, lipid-lowering therapy) and glucose-lowering therapy. Metformin has the best claim for first linetherapy for Type 2 diabetes in the presence of obesity, with gliptins, gliflozins and sulphonylureas available as second line oral therapy and GLP-1 agonists and insulin as injectables. There has been interest in whether testosterone supplementation should be considered for men with Type 2 diabetes on the basis it might improve body composition and glycemia. There have been relatively few randomised controlled trials (RCTs) of testosterone in men with Type 2 diabetes. These have reported some improvement in indices of insulin resistance in testosteronetreated men, but equivocal reductions in HbA1c (e.g. ). Therefore, additional RCTs are needed to
By Prof Bu Yeap (UWA), &OEPDSJOPMPHJTU 'SFNBOUMF BOE'JPOB4UBOMFZ)PTQJUBMT Tel 9431 3229
clarify whether testosterone supplementation has any role in the management of men with Type 2 diabetes in the absence of proven androgen deficiency. Otherwise, testosterone supplementation should be restricted to men with documented androgen deficiency, who have symptoms and signs consistent with hypogonadism and confirmed low testosterone levels . Only a small minority of men with Type 2 diabetes will have underlying pituitary or testicular disease. Many may have testosterone levels in the lower end of the normal range, associated with obesity and accumulated medical comorbidities. In obese men, weight reduction (or more specifically, reduction of central adiposity) is the preferred approach and it is generally accompanied by an increase in endogenous testosterone production , potentially realising a virtuous cycle of reduced adiposity and higher testosterone concentrations.
References 1. Ding EL, Song Y, Malik VS, Liu S. Sex differences of endogenous sex hormones and risk of Type 2 diabetes. A systematic review and meta-analysis. JAMA 2006; 295: 1288-1299. 2. Yeap BB, Araujo AB, Wittert GA. Do low testosterone levels contribute to ill-health during male ageing? Crit Rev Clin Lab Sci 2012; 49: 168-182. 3. Jones TH, Arver S, Behre HM, et al. Testosterone replacement in hypogonadal men with Type 2 diabetes and/ or metabolic syndrome (the TIMES2 Study). Diabetes Care 2011; 34: 828-837. 4. Bhasin S, Cunningham GR, Hayes FJ, et al. Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2010; 95: 2536-2559. 5. Grossmann M. Low testosterone in men with Type 2 diabetes: significance and treatment. J Clin Endocrinol Metab 2011; 96: 2341-2353.
ED: Currently, the NHMRC-funded Testosterone for the Prevention of Type 2 Diabetes Mellitus in Men at High Risk (T4DM) study (www.t4dm.org.au) is recruiting men aged 50-74 with a waist circumference of 95cm or more. The study will test whether testosterone on a background of lifestyle intervention reduces the risk of Type 2 diabetes. It encourages men to take positive action to improve their health. T4DM Study Coordinators are: Fremantle Hospital, Helen Daniels 9431 3971 or 0498 588 482; and Keogh Institute, Lee Mahoney 9346 4402. O
Disclosures: The author has received speakerâ€™s honoraria and conference support from Bayer and Lilly, and is a member of a Lilly Advisory Board. He is a principal investigator in the T4DM trial (funded by NHMRC Project Grant 1030123).
Diabetes Support Groups
he main peer support group is Diabetes WA, which has a wide range of resources on its website. It has links to independent support groups including online and friendship groups both in the metropolitan and rural areas. Connect Groups has almost an identical list.
Type 1 Diabetes t :PVOH8FTUFSO"VTUSBMJBO*OTVMJO5BLFST (YWAIT, 18-30 years) has a Facebook page and meet socially. Contact: Rachel Lamb, email@example.com t 8FTUFSO"VTUSBMJBO*OTVMJO5BLFT 8"*5 30+ years) has a Facebook page and meet socially. Contact: Julie-Anne Watson, Westernaustralianinsulintakers@yahoo.com.au
t 1BSFOUTPG$IJMESFOXJUI5ZQFNFFU regularly at different locations Contact: Olivia Marcinkowski, firstname.lastname@example.org t 1BSFOUTPGUFFOTXJUI5ZQFNFFU regularly at different locations Contact: Eric Leotta, email@example.com
Type 2 Diabetes Refer to www.diabeteswa.com.au and www.connectgroups.org.au for locations and contact details of convenors. O 39
Hepatitis C (HCV) update I
n Australia, unlike the USA and the EU where several new drugs have recently been approved, treatment of hepatitis C remains peginterferon and ribavirin based. There has been an explosion of clinical trials, particularly in patients with genotype 1, using regimes that are interferon- and/or ribavirinfree with resulting sustained virological response (SVR) of 95% and above after only 12 weeks of therapy. Patients with genotype 3, however, are a more difficult group of patient to treat, with SVR around 70%.
Current therapy With the approval of first generation direct acting antiviral drugs (DAA) – telaprevir and boceprevir – triple therapy with pegylated interferon and ribavirin in hepatitis C genotype 1 patients, achieves a SVR of over 70%, but with complex regimes and significant toxicity. Patients who fail therapy (except for those who relapse) and those with cirrhosis have the poorest SVR and require longer therapy to 48 weeks. Treatment requires intensive monitoring due to toxicity, in particular anaemia and bone marrow suppression. Rash may also be a problem with telaprevir. Patients with decompensated liver disease have increased risk of infection and mortality. In genotypes other than 1, current treatment is combination therapy of pegylated interferon and ribavirin.
Recent developments Of the new drugs recently approved in the USA or EU (Sofosbuvir, Simeprevir, Daclatasvir, Asunaprevir), Sofosbuvir and Simeprevir have been submitted for approval in Australia. Sofosbuvir (Gilead) Sofosbuvir, a nucleotide polymerase inhibitor,
By Prof Wendy Cheng, )FBEPG-JWFS4FSWJDF Royal Perth Hospital given for 12 weeks in combination was found to have the same SVR (67%) as 24 weeks of combination therapy of pegylated interferon and ribavirin for patients with HCV genotype 3. Extending treatment to 16 weeks in treatment-experienced patients results in an increase in SVR from 50% to 73%. Patients with genotype 3, particularly those with cirrhosis or prior non-responders, are likely to require ribavirin +/- addition of pegylated interferon or prolonged treatment. In genotype 1, sofosbuvir in combination with pegylated interferon and ribavirin achieved SVR of 89% in non-cirrhotic patients. Fixed dose combination of two oral agents (sofosbuvir and Ledipasvir) as a single daily dose for patients with HCV genotype 1, produced a SVR of about 95% with only 12 weeks of therapy in both treatment naïve and treatment experienced non-cirrhotic patients. This would provide a simple regime with great efficacy and minimal side effects. Sofosbuvir combined with Daclatasvir (BMS) or Simprevir (Janssen) without ribavirin have also been shown to result in SVR of 93-100%. Simeprevir (Janssen) Simeprevir, a second generation protease inhibitor has the same SVR as telaprevir when used in combination with pegylated interferon and ribavirin but has the advantage of a single daily dose, without influence of food or problem with rash. Patients with genotype 1a have a lower SVR than 1b due to resistant variant polymorphism. It is currently being assessed by TGA for approval in Australia. Combination of ABT-450/r-Ombitasvir and Dasabuvir (AbbVie) The multi-targeted regime of three agents with ribavirin has been shown to result in SVR of 96% in treated naïve and those who
failed previous treatment patients with HCV genotype 1 with 12 weeks of therapy. There is no difference in SVR between genotype 1a and 1b. In patients with cirrhosis, extension of treatment to 24 weeks of therapy increases SVR from 91 to 96%. MK-5172 + MK-8742 (MSD) At the European Association for study of the Liver Conference in April 2014, the combination of MK-5172 and MK-8742, without ribavirin was shown to achieve SVR of 94-98% in HCV genotype 1 patients with cirrhosis, after 12 weeks of treatment. In difficult to treat groups such as previous non-responders and those with cirrhosis, 12-18 weeks of treatment has trended towards a high response.
4QFDJBMQPQVMBUJPOT In patients with HCV/HIV co-infection, preliminary data suggest that the SVR may be 90-100%. In patients with decompensated cirrhosis it may be safe to use a combination of new agents without peginterferon. Post transplant HCV recurrence can also be successfully treated with combination of new agents.
4VNNBSZBOEDPODMVTJPOT Combination of new antiviral agents which are interferon- and ribavirin-free can achieve SVR >90% with 12 weeks of therapy. In difficult to treat groups, in particular cirrhosis and previous non-responders, longer duration of therapy or addition of ribavirin may be required. Single daily pill of fixed dose combination of two antiviral drugs with 12 weeks of treatment can provide a convenient, effective and safe way of managing patients with HCV genotype 1. Patients with HCV genotype 3 are emerging as more difficult to treat and are currently under study. Sofosbuvir and Simeprevir are currently awaiting TGA approval in Australia. O References on request.
Scholarship gives a leg up A
pplications for the Western Cardiology Scholarship in Medicine have just opened. The scholarship will help a student with an assured place in UWA’s seven-year Doctor of Medicine (MD) course who is deemed to be experiencing financial hardship. It will be offered for the first time in 2015 with a tiered payment system:
t BZFBSGPSUISFFZFBSTPGBO undergraduate degree
t BZFBSGPSGPVSZFBSTGPSUIF.% Scholarship Applications can be made online from June 10 to October 25, 2014. Contact Ms Lauren Hubbard, UWA Medicine, Dentistry and Health Sciences, ph 6488 4205 www.development.uwa.edu.au medicalforum
Usefulness of probiotics in gut disease
By Dr Vanoo +BZBTFLFSBO (BTUSPFOUFSPMPHJTU 'SFNBOUMF)PTQJUBM Tel 9431 2300
robiotics are live microorganisms that confer a health benefit on a host when administered in adequate amounts, by way of altering the composition of gut flora. Despite a flourishing industry in probiotics, there is a shortage of good quality clinical trials, particularly randomised controlled trials (RCTs) that support the usefulness of probiotics. However, emerging evidence now points to probiotics being useful adjuncts in select clinical situations, even though the US Food and Drug Administration (FDA) is yet to approve any health claims.
Use in diarrhoeal illness Probiotics may be useful in non-severe, particularly recurrent Clostridium difficile associated diarrhoea (CDAD) as long as there are no significant co-morbidities. Two meta analyses in 2012 suggested that a combination of Lactobacillus acidophilus, L.casei and Saccharomyces boulardii generally at a dose of over 10 billion colony forming units/day might be useful adjuncts in recurrent disease. Benefit from routine use of probiotics to prevent CDAD is uncertain. The PLACIDE study (Lancet, 2013), a large randomised controlled trial of 2941 elderly adults, failed to show a risk reduction for CDAD. A Cochrane review in 2013 consisting of 23 RCTs and 4213 patients concluded that the evidence for probiotics in this context is of moderate quality. Two meta analyses based on five and seven RCTs, respectively, indicated that those that received S. boulardii reduced the duration of acute childhood diarrhoea by several days when compared with controls. Administration of Lactobacillus GG in oral rehydration salts in a multicentre European study of 287 &7*%&/$&'0313*0#*05*$64& children aged under three years, reduced hospital stay and duration Applications with Strong Evidence of symptoms. Eight out of ten controlled trials in adults using S. boulardii for the prevention of antibioticassociated diarrhoea (AAD) showed significant efficacy. Two RCTs in children showed that the S. boulardii groups had lower rates (between 7.5% to 30%) of AAD compared to controls.
Specialists in Reproductive Medicine & Gynaecological Services
the future of Gynaecological Laparoscopic Surgery? The most recent meeting of AGES was held in Sydney and focussed on applying Robotic Surgery in gynaecology. In the USA around 3000 da Vinci Robots are in daily use shared equally between Urologists (for prostatectomies) and gynaecologists (for hysterectomies, myomectomies and excisional endometriosis surgery). In Australia there are several in current use by gynaecologists in the east (including Adelaide) but so far in WA only Urologists are using the one Robot based at SJOG Subiaco. They have performed around 1000 prostatectomies with excellent results reported. 0\Ă€UVWXVHRIWKHODSDURVFRSHZDVDW.(0+LQDQGPDQ\ Australian Gynaecologists have attained the highest skills category of Level 6; subcategorised for benign or oncological procedures. For those of us with such extensive training and expertise, using the Robot SURYLGHVQRDGGHGEHQHĂ€W but confers added costs and extended procedural time.
Robotic laparoscopic instruments in place in a gynae patient at Epworth Hospital in Melbourne.
Applications Showing Promise t "UPQJDFD[FNBJODIJMESFO t 1SFWFOUJPOPGOFDSPUJTJOH enterocolitis in neonates No Good Evidence t $SPIOTEJTFBTF t 1SFWFOUJPOPGBMMFSHJDDPOEJUJPOT t 6MDFSBUJWFDPMJUJT t *OGBOUJMFDPMJD
Irritable bowel syndrome & inflammatory bowel disease A meta analysis of 18 RCTs reported that probiotics reduced persistence of IBS symptoms, however there was significant heterogeneity among the trials and many studies continue to lack a clear prior definition of what constitutes a patient responder. Thus the data does not support routine use of probiotics in this rather heterogenous condition. Cochrane reviews for use of probiotics in inducing remission in Crohnâ€™s disease (2008) and maintaining remission in ulcerative colitis (2011) found insufficient evidence for making any conclusions on the efficacy of probiotics. O
by Medical Director Dr John Yovich
t 3FDVSSFOU$EJGGJDJMFJOGFDUJPO t 1PVDIJUJT t "DVUFJOGFDUJWFEJBSSIPFBJO children
The surgical construction of an ileal pouch anastomosed to the anus is standard treatment in cases of ulcerative colitis after proctocolectomy. Probiotics in the form of eight subspecies of bacteria labelled as VSL#3, have been found to be more effective in maintaining remission in pouchitis, than placebo, after antibiotic induction.
PIVET MEDICAL CENTRE
+RZHYHUWLPHVDUH changing and current trainees in gynaecology indicate an emerging workforce of mostly females with markedly reduced work-hours from the established VHQLRUVLQFOXGLQJ5$1=&2*DSSURYHGMREVKDULQJDWKRXUV per week. In this changed setting it appears that the da Vinci Robot with its many advances (including 3-D imaging, wristed LQVWUXPHQWVZLWKGHJUHHVRIDQJXODWHGPRYHPHQWDQG stabilised picture) could become an essential tool for complex gynaecology.
Colleague Dr Ken Leong at da Vinci console controlling robotic instruments ZLWKĂ€QJHUVKDQGVDQGIHHW
NOW AT 2 LOCATIONS PERTH & BUNBURY
For ALL appts/queries: T:9422 5400 F: 9382 4576 E: firstname.lastname@example.org W: www.pivet.com.au
Control Q â€™Turning on a sixpenceâ€™ in Port Hedland harbour.
When Ralph Waldo Emerson said famously â€œLife is a journey, not a destinationâ€? he was probably on a cruise ship! While he may have been a little sceptical about the efďŹ cacy of cruise-life before he embarked, itâ€™s a good bet he was a total convert by the time he disembarked. Cruising is, as the name suggests, a one-way ticket to relaxation, via a few exciting stopovers. Cruising is becoming increasingly popular with Australian travellers as cruise ships make more local docks their ports of call. 5PVSJTN"VTUSBMJBSFQPSUTUIBUJO DSVJTF TIJQT DBSSJFE QBTTFOHFST JOUP and out of local ports earning a cool $1.3b GPSUIFOBUJPOBMFDPOPNZoJO'SFNBOUMF UIF GJHVSFJTFTUJNBUFEBUN But back to the journey (and not the economJDSBUJPOBMJTUTEFTUJOBUJPO 8"JTJODSFBTJOHMZ JODMVEFE PO UIF DSVJTF NBQ XJUI 'SFNBOUMF becoming a popular stop for cruise companies either repositioning for the Asia circuit or visiting Down Under during the off-season of the lucrative Chinese tourism market. "OE OPX NPSF DSVJTF MJOFT BSF BEEJOH 1PSU Hedland as a stopover, which is a salient lesson in seeing through othersâ€™ eyes. 1PSU)FEMBOEJTUIFNJOJOHCPPNTHBUFXBZ and one of the busiest ports in the region and for some, a big tourist attraction. *U XBT B TUPQPWFS GPS 3PZBM $BSJCCFBOT 7PZBHFS PG UIF 4FBT SFDFOU SFQPTJUJPOJOH cruise to Singapore via Bangkok and Ho Chi Minh City. 5IF 7PZBHFS PG UIF 4FBT JT OPU 3PZBM Caribbeanâ€™s biggest ship but big enough to have seven decks accommodating 3100 pasTFOHFSTBOEDSFX$BCJO iTUBUFSPPNw TJ[FT WBSZ CFUXFFO TR GU XJUI BO PDFBO 42
WJFX CBMDPOZ BOE IBMG UIBU TJ[F XJUIPVU B WJFX 5IFSF BSF B OVNCFS PG DBCJO PQUJPOT UIBUDPTUCFUXFFOBOEQFSQFSTPO"CBMDPOZJTXFMMXPSUIUIFFYUSB FWFO though time in the cabin is minimal for most. 0G UIF EBZT PO CPBSE OJOF BSF MFJTVSFMZ cruising the open sea while there are stopPWFST PG WBSJPVT MFOHUIT o 1PSU )FEMBOE GPS eight hours, Bangkok for nearly two days and )P$IJ.JOI$JUZGPSIPVST If you think you could suffer from cabin fever GPSOJOFEBZTBUTFB UIJOLBHBJO7PZBHFSPG the Seas is a pleasure palace complete with mini-golf, top deck jogging track, swimming pools and spa pools, rock climbing wall, UIFBUSF% DJOFNB DBTJOP JDFTLBUJOH SJOL 5JNF;POF HZNOBTJVN CFBVUZTQBT SPMMFS blading, library and myriad of restaurants and bars. 'PS QBSFOUT PG ZPVOHFS DIJMESFO UIFSFT BO accredited child minding service so you can indulge in the activities or simply flop on a deckchair. Each night there is a live performance in the UIFBUSFBOEUIFZBSFUPQDMBTT*GUIF7PZBHFS DSVJTFPVUPG'SFNBOUMFJTBOZUIJOHUPHPCZ FYQFDU QJBOJTUT WJPMJOJTUT 3PZBM $BSJCCFBO singers and dancers, female vocalists, comeEJBOT KB[[TJOHFSTBOECBOE At the stopover destinations, passengers IBWF UIF PQUJPO UP QSFCPPL B TIPSF FYDVSsion to take in the main sights. 0OF FYDVSTJPO JODMVEFE MVODI BU UIF Wentworth Hotel in Ho Chi Minh City, where delectable food came with an enthralling conversation with other passengers and crew. Itâ€™s not every day you can chat to a young 6LSBJOJBOJDFTLBUFSBOEFYBDSPCBUBCPVUIFS GBOUBTUJD JDF TIPX PWFS B TQJDZ 7JFUOBNFTF CBORVFU 5IFSF JT UIF VTVBM MJGFCPBU ESJMM XIJDI JT BO entertainment itself as crew muster loitering (usually Australian) passengers and thereâ€™s the fascination of witnessing the skilled
Q Yes, shopping an this is inside the ship Vo d drinking m all with casi yager â€“ no below
NBOPFVWSJOH JOUP QPSU 5IF 7PZBHFS DBO UVSOPOBTJYQFODF UIBOLTUPUIFMBUFSBMCPX thrusters and two rear propellers, which can CFSPUBUFEEFHSFFT5IFFMFDUSPOJDOBWJgation and steering system is sophisticated, with an autopilot to track its true course VTJOH 3VTTJBO BOE 64 (14 TBUFMMJUFT 5IFSFTBCSJEHFWJFXJOHXJOEPXGPSUFDIOPMogy junkies. 'PS DSVJTF TDFQUJDT JU JT XPSUI HJWJOH B go â€“ there are cruises of various lengths and durations and more are stopping at 'SFNBOUMF0ODFZPVHFUZPVSTFBMFHT UIF cruise options are endless floating to just about every corner of the globe. 5IF POMZ SFNJOEFST BSF UBLF ZPVS QPXFS adaptor; pre-order your wine before boarding to save money; take out insurance as Medicare doesnâ€™t cover costs once youâ€™re on board, not even if you are sailing between Australian ports; and remember to look down at the floor of the shipâ€™s lift â€“ it will tell you what day it is â€“ your only reminder of the world outside.O
By Dr Barry Bridges medicalforum
Q It is customary to get some good pre-wedding photos in Vietnam; in this case in the middle of traffic in front of the Frenchbuilt Notre Dame look-alike in Ho Chi Minh City.
Q The on-board theatre begins to fill for the farewell show.
Q Exercise is best around dawn in the tropics, before the heat sets in.
KANGAROO ISLAND FOOD SAFARI from $7349
KI Food Safari runs 2–9 August 2014 and is a hands-on discovery of Kangaroo Island’s best produce. Pluck marron and abalone from the farm and enjoy fine winery lunches and dinner with the day’s harvest celebrated in a spectacular menu. Includes 7 nights at the Southern Ocean Lodge, all main meals and drinks, transfers and guest appearances including Maggie Beer and Mark Best.
Shop C7, Currambine Central, 1244 Marmion Avenue, Currambine Freecall 1800 605 044 travel-associates.com.au/brice *
Flight Centre Travel Group Limited (ABN 25 003 377 188) trading as Travel Associates. Lic No. WA 9TA589. TAADV60314
Hanging out for the
FREMANTLE DOCTOR Despite a busy medical practice blending military work, rural locums and a regular stint at the Armadale ED, Dr Ruth Highman still finds time to hit the ocean waves in her paddle ski. Working for the Australian Army is a great ďŹ t for Dr Ruth Highman. The former international ocean paddler identiďŹ es closely with the collaborative teamwork inherent in military culture and a patient cohort with a strong commitment to performing at an elite level. And Ruthâ€™s base at Leeuwin Barracks is only a few paddle-strokes from her beloved *OEJBO0DFBO
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i" MBSHF DPNQPOFOU PG NZ XPSL XJUI UIF Army is injury management and rehabilitation and itâ€™s given me more insight into the significance of just what an injury can mean for military personnel. My competitive ocean paddling dovetails nicely with the militaryâ€™s focus on physical training and maintaining a IJHIMFWFMPGGJUOFTTw
i5IFVTVBMSBDFEJTUBODFGPSPDFBOQBEEMJOH JTLNBOEPVSTPMFJOUFOUJPOJTUPQBEEMF downwind. We love the souâ€™wester every BGUFSOPPOBOENPTUPGUIF*OEJBO0DFBOQBEdlers have the Wind Guru forecast set as PVS )PNFQBHF 5IFSFT OPUIJOH CFUUFS UIBO skating along on the swells with the wind at ZPVSCBDLw
i"SNZ QFSTPOOFM IBWF TJNJMBS QFSTPOBMJUZ traits to those in medicine. As doctors, we PGUFO FYIJCJU QFSGFDUJPOJTU BOE IJHIMZ ESJWFO behaviour and, if itâ€™s not managed well, it can CFBMJBCJMJUZw
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"GUFS HSBEVBUJOH GSPN 68" JO 3VUI FOSPMMFE JO UIF 3VSBM (1 1BUIXBZ QSPHSBN with an anaesthetics specialty.
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i"GUFS*EJETPNFNPSFUSBJOJOHJO&NFSHFODZ medicine and did stints in Broome and Albany plus 18 months in Geraldton which, for me, XBT(1VUPQJB5IFXPSLMPBEIBEBXPOEFSGVMNJY JODMVEJOHBOBFTUIFUJDTw i$PNQFUJUJWF QBEEMJOH ESFX NF CBDL UP 44
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beating another person. In two of the most satisfying races of my career I was third BDSPTTUIFMJOFw i4PNF QFPQMF IBWF B SPNBOUJDJTFE WJFX PG JOUFSOBUJPOBM DPNQFUJUJPO CVU JUT RVJUF demanding. Itâ€™s a competitive mindset, youâ€™re there to do perform and, in the end, I KVTUXBOUFEUPFOKPZNZPWFSTFBTIPMJEBZTw 'PS B DPVQMF PG ZFBST UIFSF XBT B TUBOEJOH joke about the wind or, more specifically, a MBDLPGJUXIFO3VUIUVSOFEVQUPDPNQFUF i* XBT LOPXO BT A%FBUI UP 8JOE CFDBVTF every international race I entered, we hardly ever got a downwind event. And without the XJOE BOE UIF XBWFT LN JT B MPOH IBSE GMBUXBUFSQBEEMFw A transition from an intense training schedule JT BMXBZT QSPCMFNBUJD BOE 3VUI JO IFS PXO XPSET JTAUSFBEJOHXBUFSBTUPXIBUTOFYU i* MPWF XPSLJOH JO B UFBN FOWJSPONFOU BOE the interactive, collaborative approach of the Army suits me well. Iâ€™m still doing rural locums, recently in Broome and Geraldton, and I continue working a day a fortnight in the ED at Armadale in an effort to maintain NZ&%TLJMMTw i*NJOUFSFTUFEJOTQPSUTNFEJDJOFTP*NBZ well do a Masters in Sports Medicine. But I also recently did some medical student tutoring which I enjoyed immensely so that JTBOPUIFSBSFB*NLFFOUPQVSTVFGVSUIFSwO
Mr Peter McClelland
i*WF BMXBZT QVTIFE NZTFMG UP BDIJFWF UIBU FYUSB o UP TFF XIBU *N DBQBCMF PG And itâ€™s not always about winning races or
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2011 Kimâ€™s Chardonnay (Wilyabrup) 5IJTMJNJUFESFMFBTFPGCPUUMFTXBTBHFEJOOFX'SFODIPBLDBTLTGPS months although the oak is not at all apparent. It is a fine elegant style with VOEFSMZJOHSJDIOFTTPGGSVJUBOEBMFNPOZBDJEJUZ5IJTUPQGMJHIUDIBSEPOOBZ XIJDI is very skilfully made, commands attention with good food.
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2010 Shiraz (Wilyabrup) )FSFUIFSFJTTBWPVSZTQJDFPGTIJSB[XJUITPGU TVQQMFNPVUIGFFM5IFSF JTFYDFMMFOUVTFPG'SFODIBOE"NFSJDBOPBLNBLJOHUIJTBOBUUSBDUJWFBOE approachable wine.
2010 Kelseaâ€™s Cabernet Sauvignon (Wilyabrup) 5IJTJTBMJNJUFESFMFBTFPGCPUUMFTBOEJUTBDMBTTZFGGPSU3JDI SJQF DBTTJT IJOUTPGCMBDLPMJWF5IFSFJTEFQUIPGGMBWPVSXJUIBMPOHQFSTJTUFOUGJOJTIBOE TIPXTGJOFPBLUSFBUNFOU"DMBTTJD8JMZBCSVQDBCFSOFUJOUIF#PSEFBVYTUZMFUIBU stands in good company with the many illustrious wines emanating from this subregion.
8*/BDoctor's Dozen! Which doctor owns Knee Deep and what is his specialty? Answer:
&/5&3)&3&... or you can enter online at www.MedicalHub.com.au! Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, June 30, 2014. To enter the draw to win this month's Doctors Dozen, return this completed coupon to 'Medical Forum's Doctors Dozen', 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.
E-mail: ......................................................................................................... Contact Tel:
Please send more information on Knee Deepâ€™s offers for Medical Forum readers.
It was 36 years ago that The Beatles had fans and critics agape at the audacity of their ninth studio album. Some of Australia’s best musicians relive the magic. 8IFO5IF#FBUMFTSFMFBTFEJUT The White Album, it was heralded as a challenging and ground-breaking musical collage and it’s been held up by musicians ever since as a benchmark.
“To be able to harness Tim’s amazing performance skills is wonderful. It works well having the different personalities and musical styles because that taps nicely into The Beatles diversity. We’re always aiming for a smooth blend of sound and the backing band is amazing so that makes it easier.”
that any of these songs would be performed in a concert setting.”
Five years ago, a group of Australian musicians of diverse backgrounds pulled together a White Album tribute and it returns to Perth next month at the Riverside Theatre. Tim Rogers (You Am I), Chris Cheney (Living End), Phil Jamieson (Grinspoon) and indy rocker Josh Pyke join a 17-piece rock orchestra to present the playlist of the original recording.
Josh freely admits to some performance anxiety, particularly before the first tour in 2009.
“Any album spanning tracks like ‘Revolution’, ‘Ob la di’ and ‘Blackbird’ will always travel pretty well.”
“I’ve only ever done this sort of thing with the White Album. I’m not too comfortable doing the spoken word stuff on a song like ‘Rocky Racoon’ and I’m never going to be a flamboyant, extroverted performer.”
“We were amazed at the size of the crowds. None of us had done this sort of thing before and the audience was going nuts! We’d come off stage and ask each other, ‘what happened out there?’ It’s an absolutely amazing show to do.” O
“We’ve made some subtle changes from the initial tour and the encore material will be a little different. Having said that, it’s the Beatles’ White Album and you can’t mess with that too much,” said Josh Pyke.
“The first tour was really daunting, I was the newest guy in the group but now I’ve got five more years of performance miles under my belt so I’ll be more comfortable and not freaking out like last time.”
“The show opens with the album’s first track and ends with the last. There are 30 songs so that means some pretty intense practice sessions. We all do a fair bit of individual preparation so we’re ready to step on-stage and nail it for the the first big production rehearsal.” 46
Q Josh Pyke, insert, joins Phil Jameson, Chris Cheney and Tim Rogers on stage.
Music critics regard The White Album as a challenging body of music. Josh agrees and also feels that the songs, despite being of their time, travel well. “There’s a lot more going on in this recording than most people realise. It was a highly experimental project and, it has to be said, they probably never thought
“Some of the tracks are absolutely timeless. You hear little acoustic vignettes from ‘Blackbird’ on so many different CDs these days and you can see the Paul McCartney style of writing in a lot of contemporary songwriters.”
Mr Peter McClelland
8*/ 'PSZPVSDIBODFUPXJOUJDLFUTUPUIF White Album DPODFSU 3JWFSTJEF5IFBUSF 1$&$ +VMZ QN HPUP www.medicalhub.com.au
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QQThe Bacon Tree 5XP.FYJDBOTBSFTUVDLJOUIFEFTFSU after crossing into the United States, wandering aimlessly and TUBSWJOH5IFZBSFBCPVUUPKVTU lie down and await death when all of a sudden Luis says... i)FZ1FQF EPZPVTNFMMXIBU *TNFMM &FTCBDPO *UIFFOLw
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C I S S A L C S
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By all means letâ€™s be open-minded, but not so open-minded that our brains drop out. â€“ Richard Dawkins
'SSP 'SPN%S+PIO2VJOUOFS 'SP SPN% N %SS+ N%S +PIO +PIO PPIIIOO 2 2VVJOU J UOF OFSS
From: Letter to Matthew Dobson, MD by William Cullen, circa 1776. I think myself much obliged to you for the communication of your experiments (on the Urine in Diabetes), and you do me a great deal of honour in asking my opinion of them â€Ś I think you have made a discovery. Many have taken notice of the sweet taste of the urine in diabetes â€Ś you have done much more by shewing that a saccharine matter is present in considerable quantity, that such matter is present in the serum, and therefore it must arise from a defect in the power of sanguification, if I may so speak.
The Eight-Second Consult By Ms Wendy Wardell
Is this a radical new way to save to save money, or is it simply good consumer-driven medicine?
f youâ€™re wondering why your patients donâ€™t seem to listen to you any more, relax. Itâ€™s not you, itâ€™s them. Recent research has confirmed that human attention span is decreasing to a point where we could all be clinically diagnosed as butterfly brains. Some researchers have it as low as eight seconds, which makes the goldfish, at nine seconds, a paragon of focused concentration. Itâ€™s just a shame that possession of fins makes them unsuited for careers we can no longer handle, like bomb disposal or professional gambling. Given the inability to focus on one thing for longer than the blink of an eye, itâ€™s lucky that as a society, weâ€™ve already done the hard yards in discovering the secret of fire and inventing the wheel. Doubtless nowadays weâ€™d be too distracted to get around to it. Having a short attention span isnâ€™t all downside though. In the recent Senate elections, each advert for the Palmer United Party would have seemed constantly new, fresh and exciting. Iâ€™m trying, but still canâ€™t find this other than deeply depressing. The secret to capturing more than a
Wilbur and Orville Wright
Looked at birds and thought it would be cool to fly. Drank 3FE#VMMBOEHPUOFBSFOPVHI4QFOUBGUFSOPPODIBTJOHDBST
moment of peopleâ€™s attention now is to make everything a form of entertainment. This is where infectious diseases have cornered the market. Devious new flu bugs are reinventing themselves and finding ever more sinister ways of overcoming our resistance, much like Moriarty or Lady Gaga. Ebola has the gore of Game of Thrones and the exotic location of a David Attenborough doco. Superbugs are the arch nemesis of wily medicos who combine the wit and intelligence of Stephen Fry with the raw sexuality of Daniel Craig (thankfully, not the other way around), and, of course, the sunny disposition of House. Iâ€™m afraid this is the competition that
youâ€™re up against if youâ€™re trying to make people pay rapt attention to their fatty liver or dicky pancreas. What Peter Jackson did for New Zealand with Lord of the Rings could so easily be turned to the cause of regular prostate checks with a decent budget and a shed full of computer geeks, who donâ€™t get out much. Think Indiana Jones retreating at speed from a giant gallstone bearing down on him, or a Twilight-themed Haemochromatosis Awareness Week. Blood and squelchy bits are just another day at the movies for fans of the 300 franchise and will have little impact emblazoned on cigarette packets. But the day that a blackened and downcast Wile E Coyoteâ€™s smoking habit is shown to again thwart his pursuit of Road Runner will be the day smokers start to understand the error of their ways. After all, you rarely see anyone attaching jet packs to roller skates or throwing anvils off cliffs any more do you? The Medical Board would be a bit dark about it, but maybe they need new direction. I think Kermit the Frog might be just the amphibian for the job and he could even distract those irritatingly intense goldfish. O
Clinic The Holly wood e Hollywood
ent of Th The redevelopm 70-bed grow from a 40 to it en se Clinic has in M ister for s opened by the facility, which wa last month. n s Helen Morto Mental Health M ng and ni di de also inclu The new facilities y room. ap er th d an d urtyar lounge rooms, co Pic tures: Alana Blo
Q(Top left clockwise) Hollywood Hospital Director of Medical Services Dr Daniel Heredia, Chair of the clinicâ€™s Psychiatric Advisory Committee Dr Matthew Samuel, Mental Health Minister Ms Helen Morton, and Hollywood Hospital Director of Clinical Services, Ms Karen Gullick. Hollywood Hospital CEO Mr Peter Mott, Minister Morton, and Ramsay Regional Manager Mr Kevin Cass-Ryall. Hollywood Clinic psychologists Ms Sue Aston, Dr Fiona Cartwright and Dr Stephanie Oâ€™Toole. Mr Kevin Cass-Ryall, CEO of NMHS Dr Shane Kelly and Hollywood Clinic psychiatrist Dr Michael Woodall.
ACTION HERO on and OFF STAGE From swashbuckling hero to directing an edge-of-your-seat thriller is all part of the theatrical life for Stuart Halusz. #MBDL4XBO4UBUF5IFBUSF$PNQBOZT TFBTPOJTGVMMPGmSTUT'PS BDDMBJNFE1FSUIBDUPS4UVBSU)BMVT[ itâ€™s taking the helm this month of his ďŹ rst main stage production as director in a world premiere. House on the Lake is Melbourne playwright Aidan Fennessyâ€™s new play and is a vastly different landscape from his much-discussed National Interest, which explored the deaths of five Australian journalists at the hands of invading Indonesian forces in East Timor in 1975. Stuart performed in National Interest several years ago and it gave him the chance to watch Fennessy (who also directed that play) at close hand. â€œHe is a very lyrical writer who is very engaged in words and imagery. In House on the Lake he uses them to great effect to create a gripping psychological thriller,â€? Stuart said. The set-up sees lawyer David Rail (played by Kenneth Ransom) waking up in a hospital room suffering from anterograde amnesia. He can remember in detail everything up to the point of trauma and Dr Alice Lowe (played by Norwegian actor Marthe Rovik) attempts to help him remember. 50
â€œItâ€™s set in one room and is intense for actors and audience as his returning memories unfold. Itâ€™s a classic whodunit but also a deeply psychological piece that explores memory, time and space and how they shift in our lived experiences. It will have the audience on the edge of their seats.â€? Directing a new work is both liberating and an enormous responsibility but Stuart clearly relishes the task of building a production, working with set and costume designer India Mehta, lighting designer Trent Suidgeest and sound engineer Brett Smith to create a moody, atmospheric show. â€œAs this is the premiere, a lot of thought has gone into every aspect of the production because, in a way, we are setting its style for others to consider.â€? Not surprisingly, Stuart spent some time casting this two-hander knowing how important it is to get the chemistry spot on and he believes Marthe and Kenneth have a firm grip on this rollercoaster of a story. But how has it been for the stalwart actor to take the reins and tell his colleagues what to do? â€œThe Perth theatre community is tight and supportive and everyone was thrilled that I was taking the job. For Ken and I, we
Q Stuart Halusz
know each other so well as fellow actors, we are comfortable having conversations with each other. Both Ken and Marthe are hard-working, deep-thinking actors and have brought some great ideas to the table.â€? For the moment, Stuart is happy to balance a life on both sides of the footlights. Currently heâ€™s entertaining school children with his own production, Shakespeare Shenanigans, a work based on the many fight scenes in Shakespeare plays. He and his friend, theatrical fight coordinator Andy Fraser, swashbuckle their way through half a dozen plays, sweeping up delighted kids as they go. â€œFor some of the kids, itâ€™s their first experience of theatre, so itâ€™s a very exciting project.â€? â€œDirecting has long been a distant goal but I still enjoy performing. I am just totally engaged in the storytelling capacity of theatre no matter what I do.â€? O
By Ms Jan Hallam QHouse on the Lake opens in the Studio Underground, State Theatre Centre, June 6â€“22. Medical Forum performance, June 14.
Entering Medical Forum's $0.1&5*5*0/4 is easy! Simply visit www.medicalhub.com.au and click on the '$0.1&5*5*0/4' link (below the magazine cover on the left).
Movie: Cavalry 5IFUBMFOUUIBUXBTCFIJOEUIFCSJMMJBOU*SJTICMBDLDPNFEZ The Guard, is back with Calvary, which caught the eyes of judges at the Sundance and Berlin film festivals. Brendan Gleeson is 'BUIFS+BNFT-BWFMMFXIPJTJOUFOUPONBLJOHUIFXPSMEBCFUter place, but he is continually shocked by the nasty inhabitants of his small country town. In cinemas, July 3
Movie: Deliver Us from Evil &SJD #BOB IJUT UIF CJH TDSFFO BHBJO XJUI UIJT HSJUUZ /FX :PSL crime drama. Bana plays a struggling cop who discovers crimes which are occult related. He seeks help from an unconventional priest to aid him in the investigation. Itâ€™s based on a book of a real-life copâ€™s bone-chilling cases. In cinema, July 31
5IFBUSF#FMM4IBLFTQFBSFT)FOSZ7 -BTUZFBSXBT)FOSZ*7OPXTFFXIBU1SJODF)BMEPFTOPXIFT BMM HSPXO VQ 5IJT QPXFSGVM QMBZ IBT CFFO JOUFSQSFUFE CZ UIF Bell company through the eyes of young boys caught up in the -POEPO #MJU[ XIP QVU PO QMBZT UP LFFQ VQ UIF TQJSJUT PG UIPTF huddled in bomb shelters. Heath Ledger Theatre, July 23-26, 7.30pm
0QFSB5IF.BHJD'MVUF .P[BSUTNBHJDBMNZTUFSZUPVS The Magic Flute JT8"0QFSBT XJOUFS XBSNFS 1SJODF 5BNJOP SFDFJWFT B NBHJD GMVUF GSPN UIF 2VFFOPGUIF/JHIUBOETFUTPVUUPSFTDVFIFSEBVHIUFS1BNJOB from an evil priest. Betrayal, reprisals, deceptions and mayhem ensue. Sung in English. His Majestyâ€™s Theatre, Medical Forum, July 15 (season continues until July 26), 7.30pm
Movie: Dawn of the Planet of the Apes (3D) We have only just got over the devastating final scene of the 1968 Planet of the Apes and endured a GFXTJMMZTFRVFMTBOE57TIPXTJOCFUXFFOBOEOPX XFIBWFBTFSJPVTDPOUFOEFSTUBSSJOH(BSZ0MENBO and Andy Serkis (Lord of the Rings fame). A growing nation of genetically evolved apes is threatened by a band of human survivors of the devastating virus. In Cinemas, July 10
Doctors Dozen Winner "(MBTTPO the Hill %PDUPST 5IF #SPXO )JMM &TUBUF SFTTJWF JNQ Z MBSM UJDV QBS B JT %P[FO BS Dr JTUS 3FH DBSUPO PG XJOF (1 smiling the s wa l, rel Du l Crysta forward to recipient and is looking M JT RVJUF TUB $SZ JUFT XI UIF USZJOH vignon Sau illon partial to a Sem ebrate cel to d nde inte and Blanc h family and friends. wit ss gla a Motherâ€™s Day with
Kidsâ€™ Theatre: The Little Prince 4QBSF 1BSUT 1VQQFU 5IFBUSF IBT BEBQUFE UIF DMBTTJD UBMF CZ "OUPJOFEF4BJOU&YVQFSZJOUPBUJNFMFTTTUPSZBCPVUUIFJNQPSUBODFPGGSJFOETIJQ5IF-JUUMF1SJODFMFBWFTIJTUJOZIPNFQMBOFU for Earth where he meets an oddball cast with some very silly ideas about the things that really matter. Spare Parts Puppet Theatre, Fremantle, Medical Forum, July 5, 1pm (season continues July 19) MEDICAL FORUM $ 10.50
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Musical Theatre â€“ Admission One Shilling: Dr Moira Westmore Movie â€“ Healing: %S&TUIFS.PTFT %S"EFMJOF'POH %S5SJTI5IFJTJOHFS %S+FOOZ)BSU %S+BNFT-BUUP Dr Christina Wang, Dr Amet Malik, Dr Monica Keel Movie â€“ Spanish Film Festival: %S4VF#BOU %S)FMFO4MBUUFSZ %S4V[BOOF.D&WPZ %S)BSTIB $IBOESBSBUOB %S"NZ(BUFT %S.BY5SBVC %S(BCSJFMMB5BMMNBO %S7JODFO[B'SJTJOB %S"OHFMP$BSCPOF Dr Geoff Mullins Movie â€“ Sunshine on Leith: %S+PIO#FMM %S#JCJBOB5JF %S'JPOB8IFMBO %S%POOB.BL %S4JNPO.BDIMJO %S"OESFX5PGGPMJ %S1IJMPNFOB'JU[HFSBME %S)FSUIB$PMMJO %S:PIBOB,VSOJBXBO Dr Boey-Leng Loy Movie â€“ Fading Gigolo:%S3VCZ$IBO %S-BXSFODF$IJO %S+VMJB$IBSLFZ1BQQ %S#SZOF3FEHSBWF .T.BHEBMFOB+VFOHMJOH %S1BVM,XFJ %S)FMFO)BOLFZ %S$PMJO4UFXBSU %S4BOKBZ,BOPEJB %S$BUIZ,BO
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medical forum FOR LEASE
RAVENSWOOD Medical PremisesÂ Ravenswood WAÂ seeking medical specialists , diagnostic, dentist, occupational therapist, chiropractor, optician and others. Approx 10 km from the nearest medical facility. A pharmacy is already operating on-site. Plenty of parking and attractive leasing terms on offer. For further information please contact Rick Bantleman of Century 21 Centex Commercial on 0413 555 441 or Otto Allen Grossman on 0419 819 737. MURDOCH Medical Clinic SJOG Murdoch Specialist consulting sessions available. Email: email@example.com
APPLECROSS Applecross Medical Group is a major medical facility in the southern suburbs. Current tenants include GP clinic, pharmacy, dentist, physiotherapy, fertility clinic and pathology. Both the GP clinic and pharmacy provide a 7-day service. The high profile location (corner of Canning Hwy and Riseley Street Applecross), provides high visibility to tenants in this facility. A long term lease is available in this facility - with the current layout including 4 consulting rooms, procedure room and reception area. Would suit specialist group, radiology or allied health group. Contact John Dawson â€“ 9284 2333 or 0408 872 633
WINTHROP MURDOCH Murdoch Specialist Centre, brand new stylish large rooms. Please email you interest to firstname.lastname@example.org
WEST LEEDERVILLE Doctors Consulting Suites. Areas up to 250 sq m. Close to St Johnâ€™s Subiaco Onsite Parking Easy access to Freeway/Bus /Train Phone 9380 6457 MURDOCH SJOG Murdoch Medical Clinic within SJOG Hospital - 95sqm on 1st floor, close to lifts - Secure, undercover car bay $VSSFOUMZDPOTVMUSPPNT XXBUFS - Large recept, waiting room & kitchen - One of only few suites with private WC - Ducted R/C airconditioning - Available f/furnished mid-late June The perfect suite for the medical specialist or allied health service where a private Toilet is required or preferred Frana Jones 0402 049 399 Core Property Alliance 9274 8833 email@example.com
OSBORNE PARK Scarborough Beach Road Exposure â€˜Bargain basement rentalâ€™TRN Good size consulting rooms available â€“ up to 500sqm. Premises suitable for Specialist, Allied Health Services (eg. Psychology, Physiotherapy etc) Medical Centre located in the same building. Easy access and plentiful free parking. Please contact Michael on 0403 927 934 Email Dr Dianne Prior: dianne@ duncraigmedicalcentre.com.au
One consulting room within newly fitted Specialist suite at Winthrop Professional centre. *NNFEJBUF'VMM1BSUUJNFMFBTF Shared reception, office, kitchen, patient waiting area. *ODMVEFTGSFFTUBGG QBUJFOUQBSLJOH NJOVUFTGSPN,XJOBOBGSFFXBZ 4+0( Murdoch, Fiona Stanley Hospitals. Call Krish 0403 491 795
MURDOCH NEW Wexford Medical Centre Attached to the St John of God Hospital, in vicinity of the Fiona Stanley Hospital. Modern, newly fitted out medical consulting room. Sessional medical & dental rooms available. Please contact : Email - firstname.lastname@example.org for more information. MT LAWLEY Beautifully restored Consulting Rooms, located 150m from Mercy /St John Mt Lawley Hospital. Would suit a specialist. Ample parking at the back, some undercover. Large consulting room(s), flexible spaces. Shared reception area, toilets, waiting area and kitchen with an established Urologist specialist practice. Easy access to public transport. Telephones, computer network and medical practice software included if you are just starting out. Available immediately. Contact Stan Email: email@example.com Phone: 0407 985 755 or 9271 9066
NEDLANDS Medical Specialist Consulting Rooms and Treatment Room. Fully serviced rooms and facilities for Specialist Consulting are available including a treatment room to accommodate minor procedures. t 4VJUF )PMMZXPPE4QFDJBMJTU$FOUSF 95 Monash Avenue, Nedlands. Any enquiries can be directed to Mrs Rhonda Mazzulla, Practice Manager 4VJUF Hollywood Specialist Centre 95 Monash Avenue Nedlands, WA 6009 Phone: 9389 1533 &NBJMTVJUFIPMMZXPPE!CJHQPOEDPN NEDLANDS Consulting room available to rent to a Medical Specialist Western Dermatology is an established dermatology practice, comprising of two modern, well-equipped rooms, based at Hollywood Medical Centre in Nedlands. Due to the Principal Consultantâ€™s sessional pattern, the second room has become available for a Medical Specialist to rent for four sessions per week (Thursday morning, Friday morning, Friday afternoon and Saturday morning) with an immediate start. The room will be available for a 12 month period. Selection criteria t .FEJDBM1SBDUJUJPOFSIPMEJOH4QFDJBMJTU Registration with the Medical Board of Australia t 4FSWJDFTUIBUXPVMEDPNQMFNFOUUIF facility include Rheumatology, Cardiology, Psychiatry, General Medicine, General Surgery, Nephrology, t *NNVOPMPHZPS t*OGFDUJPVTEJTFBTFT t:PVSPXO4FDSFUBSZ This is an excellent opportunity for a Medical Specialist to start their own business or grow an already established business in the centrally-based and rapidly expanding North Metropolitan Health Service area. For a confidential discussion contact Dr Prasad Kumarasinghe, Principal Consultant on 9389 6736 or 0438 380 622
FOR SALE Expressions of interest. Solo General Practice in sought after southwest coastal town. Fully accredited, fully equipped practice in central location, walk in/walk out, low overheads. Expansion through hospital A&E work available. Low Price. Phone: 0427 727 772
LOCUM WANTED MADELEY Highland Medical Centre Madeley, looking for a locum for 8-10 weeks (June-Aug) No on call or after hours Private billing practice Best Practice Software Flexible hours Non corporate practice Contact Jacky 0488 500 153
BIBRA LAKE - Psychiatrist wanted Are you intending to start Private Practice? This is a sheer walk in! Part time, sessional or full time - all enquiries welcome. Furnished consulting rooms available at: Bibra Lake Specialist Centre, 10/14 Annois 3PBE #JCSB-BLF8" Existing private psychiatrist one day a week at this location. 7-day pharmacy and GP surgery next door are added advantages. 5 minute drive to St John of God and upcoming Fiona Stanley hospital. Phone Navneet 9414 7860
RURAL POSITIONS VACANT ALBANY t 4U$MBSFTJTBOFXGBNJMZQSBDUJDFCBTFE in Albany t 4NBMMGSJFOEMZQSBDUJDF t 'VMMUJNFOVSTJOHBOEBENJOJTUSBUJPO support t 1BUIPMPHZPOTJUF t 'VMMPSQBSUUJNF(1XBOUFEUPKPJOPVS team t 4QFDJBMJOUFSFTUJOTLJOXPVMECFJEFBM t $VSSFOUMZOP%84VOMFTTXJMMJOHUP work in afterhours period t (1TOPUSFRVJSJOHTVQFSWJTJPOSFRVJSFE Please contact practice manager Belinda Elliott Tel: 9841 8102 Email: firstname.lastname@example.org Or send your CV through and we will get back to you.
URBAN POSITIONS VACANT
Reach every known practising doctor in WA through Medical Forum Classifieds...
FOR SALE OR LEASE CANNINGTON Consulting Rooms, suit Medical or Allied. 4 Consulting / Treatment rooms, Reception, 9 Car Bays, Very close to Carousel Shopping Centre. For Details phone Gerry: 08 9350 6311
APPLECROSS Weekend Sessions and weekday afternoons available. Confidential enquiries to: PM Rita on email@example.com or 9364 6633
JULY 2014 - next deadline 12md Thursday 12th June - Tel 9203 5222 or firstname.lastname@example.org
medical forum WEST LEEDERVILLE Great Lifestyle! Part time (up to full time) VR GP invited to join long established West Leederville family practice. Computerised, accredited and noncorporate with an opportunity to 100% private bill if desired. Lots of leave flexibility with six female and one male colleague. Email: email@example.com or call Jacky, Practice Manager on 9381 7111 / 0488 500 153
PALMYRA Palin Street Family Practice requires a full or part-time VR GP. We, at this privately owned fully serviced computerised practice enjoy a relaxed environment with space and gardens. Earn 65% of mixed billings. For further information call Lyn on 9319 1577 or Dr Paul Babich on 0401 265 881.
FREMANTLE Fremantle Womenâ€™s Health Centre requires a female GP (VR) to provide medical services in the area of womenâ€™s health 1or 2 days pw. *UJTBDPNQVUFSJTFE QSJWBUFBOECVML billing practice, with nursing support, scope for spending more time with patients, and provides recently increased remuneration plus superannuation and generous salary packaging. FWHC is a not-for-profit, community facility providing medical and counselling services, health education and group activities in a relaxed friendly setting. Phone: 9431 0500 or Email: Diane Snooks - firstname.lastname@example.org or Dawn Needham email@example.com HILTON GP. Wanted / Sessional/ P/Time VR. GP. to join 25yrs established General Practice in the Hilton area; 2 GPâ€™s: Accredited. Computerised with fulltime nurse support. Service growth potential. Contact Practice Manager on 9337 8899 MT LAWLEY ECU Medical Centre, P/T VR GP required well equipped, accredited practice, RN support. Caring for University community. No weekends or after hours. Flexibility of hours and days can be accommodated. Contact Dr Rob Chander Email: firstname.lastname@example.org Phone: 6304 5618 KALLAROO North of River practice requiring A/Hâ€™s GP to work Sundays, 8 â€“ 2, private billing, with nurse support. Contact Practice Manager 0488 963 749 Email email@example.com
LANGFORD (Qualifies as DWS) Langford Medical Centre is looking for a full time GP to commence ASAP. Due to the sudden departure of a colleague, we have a ready-made full patient base for an incoming Dr. We are a modern, well equipped, accredited predominantly bulk billing practice. Situated south of the river, Langford is one of the closest practices to the CBD that still qualifies as a district of workforce shortage. For confidential enquiries please contact PM Rita on 9451 1377 NORTH PERTH View Street Medical requires a GP F/T or P/T. We are a small, privately owned practice with a well-established patient base, computerised & accredited with nurse support. Ring Helen 9227 0170
YOKINE Part-Time VR GP required for a small QSJWBUFMZPXOFEQSBDUJDFJO:PLJOF Female GP preferred to help our existing female GP . Family friendly practice with nursing support and a lovely team of receptionists. Our GPâ€™s have full autonomy. Private billing. Fully computerised. Accredited. On-site pathology. Allied health rooms attached next to the practice. Excellent remuneration is offered to the right applicant, but we are not in an area of need. Please contact Jayne Jayne@swanstsurgery.com.au or Dr Peter Cummins firstname.lastname@example.org for further information.
MANDURAH GP required for established, accredited Practice. Large client base, newly renovated, private practice. Well-equipped medical centre staffed by experienced Registered Nurses. Generous remuneration. No DWS please. No on call. Contact Ria 9535 4644 Email: email@example.com
KWINANA â€“ CHISHAM AVENUE MEDICAL CENTRE Full time or Part time VR GP required for a busy long established medical centre. Mixed billing, fully accredited with pharmacy and pathology on site. Please contact Bili on 9419 2122 or Email: firstname.lastname@example.org
SHENTON PARK Churchill Health Centre A part-time position is available up to 4 sessions per week for a GP with special interest in womenâ€™s health care and paediatrics. We have modern spacious consulting rooms and work in a friendly relaxed atmosphere with flexible working hours. We are a private billing practice so there is a guaranteed minimum income. For further enquiries or to lodge your resume please Email â€“ Marie at email@example.com
MADELEY VR & Non VR General Medical Practitioners required for Highland Medical Madeley which is located in a District of Workplace Shortage. Highland Medical Madeley is a new noncorporate practice with 2 female & 1 male General Practitioners. Sessions and annual leave entitlement are negotiable, salary is compiled from takings rather than drawings. Up to 70% of billings paid (dependant on experience) Please contact Jacky on 0488 500 153 or E-mail to firstname.lastname@example.org
SORRENTO V/R GP for a busy Medical Centre in Sorrento. Up to 75% of the billing Contact: 0439 952 979
GIRRAWHEEN Doctors required for The New Park Medical Centre Girrawheen. Opening in July 2014 we are seeking FT and PT GPâ€™s to join the team. Enquires to Dr Kiran on 0401 815 587 Email: email@example.com
NORTH BEACH Close to the beach! Opportunity for a P/T or F/T GP to join our privately-owned practice. Flexible hours and mixed billing. An interest in womenâ€™s health an advantage. On site pathology, psychologist and nurse support. Please contact Helen or David 9447 1233 to discuss or Email: reception.nbmc@ bigpond.com
WOODLANDS Woodlands Family Practice Great opportunity for FT/PT VR doctor in a well-run, newly extended, inner metro, mixed billing, privately owned practice. Call Dr Mary McNulty or Dr David Jameson, 9446 2010 or email firstname.lastname@example.org
BULL CREEK PT/FT VR GP required for Accredited, Privately owned, Friendly Family Practice Please call â€“ 9332 5556 NORTHERN SUBURBS General Practitioner wanted. An integrated health clinic in the northern suburbs is looking for a General Practitioner with a holistic approach to medicine to join our diverse team. The practice focuses on a holistic approach to health. We have a Holistic GP, Naturopath, 3FNFEJBMUIFSBQJFT $PVOTFMMJOH :PHBBOE Meditation within the practice. Practitioners work together based on the health interests of the patient. Hours are flexible and by negotiation. Must be licensed in Western Australia. *GUIJTBQQSPBDIBQQFBMTUPZPVQMFBTFTFOE your expression of interest to: Email: email@example.com
SOUTHERN SUBURB (113"$5*$&73(1 '5PS15SFRVJSFE for a privately owned Group practice. Located in the southern suburb, approximately 25 mins from the CBD. *OBQSJNFMPDBUJPO CVTZTIPQQJOHDFOUSF with good exposure and ample parking at the front and rear. Private billing, this is the perfect opportunity for an enthusiastic GP. Generous percentage offered and interest in ownership/ partnership considered. Administrative and nursing services will be provided, along with pathology collection on-site. $POUBDUFNBJMUPNBSZKBOFLQ!HNBJMDPN NEW PRACTICE - Inner Northern Suburb Located in an inner northern suburb, approximately 5 mins from the CBD. *OBQSJNFMPDBUJPOPOBNBJOSPBE XJUI good exposure and ample parking at the front and rear. Also next door to a 7-day pharmacy. With recent retirements in the area, this is the perfect opportunity for an enthusiastic GP or group of GPs. Generous percentage offered and interest in ownership considered. Administrative and nursing services will be provided, along with pathology collection on-site. Call 0414 287 537 for details. KARDINYA Kelso Medical Group requires P/T GP (DWS after hours only). This long established privately owned and managed mixed billing practice offers great opportunity for doctor with interest in CDM and minor surgical procedures. Located in Kardinya in newly refurbished premises with onsite pathology and allied health with growing patient base. $VSSFOUMZTVQQPSUFECZ(1TBOE3/T www.kelsomg.com.au Please call 0419 959 246 for further information.
JULY 2014 - next deadline 12md Thursday 12th June - Tel 9203 5222 or firstname.lastname@example.org
medical forum ARE YOU
DUNCRAIG MEDICAL CENTRE OSBORNE CITY MEDICAL CENTRE Require a female GP for both practices. Existing patient base. Flexible hours. Excellent remuneration. Modern, predominantly private billing practice with full time Practice Nurse. Fully computerised. Please contact Michael on 0403 927 934 Email Dr Dianne Prior: email@example.com
ROLEYSTONE PT/FT VR Female GP required for a GP clinic in Roleystone. A friendly and efficient working environment. Well-equipped consulting and treatment rooms, fully computerised, accredited and busy practice. Contact: firstname.lastname@example.org
We make Aged Care work for GP’s Medical Practitioners for Aged Care (MP+AC) is seeking doctors to join its team providing medical services to residents of various Residential Aged Care Facilities throughout the Perth metro area. Our efficient service delivery model maximises the doctor’s earning potential. t 'MFYJCMFTFTTJPOT.POEBZUP'SJEBZ t (SFBUBENJOTDIFEVMJOHTVQQPSU t 3FNPUFMPHJOUPQBUJFOUSFDPSET t 3/QSPWJEFECZ.1 "$UPBTTJTUEPDUPS t #FUUFSVUJMJTBUJPOPGEPDUPSTUJNF t 1BZNFOUPGHSPTTSFDFJQUT t &RVJUZJOWPMWFNFOUQPTTJCMF For more information or confidential discussion about work options please contact: Caroline Claydon - MP+AC Mobile: 0433 269 532 or Email: email@example.com CANNING VALE Canning Vale (DWS) requires full/parttime or locum VR GP urgently. Rates negotiable. Privately owned practice - fully computerised, huge consulting rooms, spacious treatment room with RN, and onsite pathology with other health alliances in the complex. Phone: Julie 9456 1900 Email: firstname.lastname@example.org
Looking for dedicated GP’s and Specialists who love the South West and want to stay – move across to our state of art practice – we have oodles of space. You can have your own room. Excellent working conditions with limited after hours needed through Bunbury After Hours GP Clinic. Contact Dr Brenda Murrison for more details!
9791 8133 or 0418 921 073 PERTH CBD Full and part time VR GPS to join our busy inner city practice located in the Hay Street Mall. Non-corporate, mainly private billing, accredited, fully computerised with full admin and nursing support and on-site pathology. Flexible hours and high earning potential for suitable candidates. Please contact Debra on 0408 665 531 to discuss or Email: email@example.com
CLAREMONT :PVLFFQPGCJMMJOHTJOUIJTCSBOE new clinic. Second branch of a very busy and well established walk-in bulk billing practice. Looking for GPs with unrestricted provider number. Located in a modern complex with free access to the gym and pool. :PVQBZPOMZBGMBUEBJMZSBUFUPDPWFS overheads To establish in this area and be your own boss, please contact Dr Ang 9472 9306 or Email: firstname.lastname@example.org
Medical Centre in East Victoria Park, Western Australia Requires GPs for weekday work. Best possible terms offered. Earn 70% of billings. Best possible location, stand-alone site integrated with a pharmacy and pathology, located next to the very busy Park Shopping Centre, ample free parking. This is a busy Medical Centre having easy access to all surrounding suburbs of Vic Park, Belmont, Bentley, Canning, and South Perth. (Non VR IMG doctors may also apply for afterhours and weekend work)
Apply now. email@example.com (Phone: 0411 87 6677) JULY 2014 - next deadline 12md Thursday 12th June - Tel 9203 5222 or firstname.lastname@example.org
Are you wanting to sell your medical practice? As WA’s only specialised medical business broker we have sold many medical practices to qualified buyers on our books. Your business will be packaged and marketed to ensure you achieve the maximum price possible.
To find out what your practice is worth , call:
Looking for a sea change?
Brad Potter on 0411 185 006
We may have the job for you.
We are committed to maintaining confidentiality. You will enjoy the benefit of our negotiating skills. We’ll take care of all the paper work to ensure a smooth transition.
If you have ﬁnished your GP training or looking for a subsequent term placement or an experienced GP looking for a change for the better, phone Jill on 08 97521133 or email email@example.com. Busselton is located on the pristine shore of Geographe Bay in the Margaret River Wine Growing region, just a short 2 hour drive from Perth.
Specialists – opportunity for easy private practice in Fremantle!
Suite 27, 782 - 784 Canning Highway Applecross WA 6153
Ph: 9315 2599 www.thehealthlinc.com.au
GPs Wanted - South Metro Multicultural Health Clinic (Belmont, 39 Belvidere Street )
*HQHURXVKRXUO\UDWHV )OH[LEOHZRUNLQJKRXUV &OLQLFDODQGQXUVLQJVWDIIVXSSRUW 0RGHUQZHOOHTXLSSHGIDFLOLWLHV )XOO\FRPSXWHULVHG
Ellen Health (Ellen Street Family Practice) will be moving from 59 Ellen Street Fremantle, to the beautiful old Beacon Theatre - 69 Wray Avenue (corner Hampton Road), Fremantle, co-located with pharmacy, pathology and allied health. Doctor-owned and managed, Ellen Health is a multi-disciplinary team, providing excellence in health care. We invite specialists to join the team, offering an instant referral base with our established general practice, and with the ease and comfort of fully serviced new rooms.
We are recruiting specialists and VR-GPs now. Enquiries to Dr Catherine Douglass 0421 520 767 www.ellenhealth.com.au
GPs Wanted - GP After Hours Clinics in Belmont, Armadale and Rockingham
*HQHURXVKRXUO\UDWHV 0RGHUQZHOOHTXLSSHGIDFLOLWLHV )XOO\FRPSXWHUL]HGDQGDFFUHGLWHGFOLQLFV 3ULYDWHDQG%XON%LOOLQJRSWLRQV &OHULFDODQGQXUVLQJVWDIIVXSSRUW For more information contact Liz Williams at 08 6253 2100 or firstname.lastname@example.org
With a reputation built on quality of ality WKH service, Optima Press has the resources, e the people and the commitment to y client provide every client with the finest DOXHIRU printing and value for money. 9 Carbon Court, Osborne Park 6017 Tel 9445 8380
Know your Score is a Prostate Cancer Foundation of Australia (PCFA) campaign encouraging men to be proactive about their health and to know their general ‘score’. PCFA are partnering with the West Australian Football Commission (WAFC) to dedicate a round of WAFL games played on 14 June 2014 to be called the Know your Score Round. Help us raise the proﬁle of prostate cancer and improve the outcomes for men dealing with this disease. KNOW
JULY 2014 - next deadline 12md Thursday 12th June - Tel 9203 5222 or email@example.com